MEDICARE: MS. DANIELA IACOBONI MS, CGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1265421192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DANIELA IACOBONI MS, CGC

Provider Business Mailing Address
First Line	:	365 PACKMAN AVE
Second Line	:
City	:	MOUNT VERNON
State	:	NY
Zip	:	10552-1025
Country	:	US
Telephone Number	:	914-668-3548
Fax Number	:	718-519-3638

Provider Business Practice Location Address
First Line	:	1400 PELHAM PKWY S
Second Line	:	BUILDING 1, ROOM 1N43H
City	:	BRONX
State	:	NY
Zip	:	10461-1138
Country	:	US
Telephone Number	:	917-738-3861
Fax Number	:	718-519-3638

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	07/08/2007

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