Healthcare Provider Details

I. General information

NPI: 1649437393
Provider Name (Legal Business Name): JANETTA LYNNE IWANICKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4507
US

IV. Provider business mailing address

2653 W 32ND AVE
DENVER CO
80211-3380
US

V. Phone/Fax

Practice location:
  • Phone: 303-436-7142
  • Fax:
Mailing address:
  • Phone: 415-205-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2731
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: