Healthcare Provider Details

I. General information

NPI: 1598709255
Provider Name (Legal Business Name): SHIRLEY ANGELA IANNAZZONE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: ANGIE IANNAZZONE CPNP

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 JOHNSON FERRY RD SCOTTISH RITE DEPT OF ANES
ATLANTA GA
30342
US

IV. Provider business mailing address

1001 JOHNSON FERRY RD SCOTTISH RITE DEPT OF ANES
ATLANTA GA
30342
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-2008
  • Fax: 404-785-4496
Mailing address:
  • Phone: 404-785-2008
  • Fax: 404-785-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN054960NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: