Provider Demographics
NPI:1053954222
Name:DIETZEL, NICOLE ANN (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:DIETZEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-2818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4636363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical