Provider Demographics
NPI:1053846162
Name:WOROSZYLO, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:WOROSZYLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45672 EDGE MILL CT
Mailing Address - Street 2:
Mailing Address - City:GREAT MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20634-3312
Mailing Address - Country:US
Mailing Address - Phone:219-306-2880
Mailing Address - Fax:
Practice Address - Street 1:1751 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14223-1211
Practice Address - Country:US
Practice Address - Phone:716-541-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024842363L00000X
MI4704380894363LP2300X
OH0030892363LP2300X
NY341686363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care