Healthcare Provider Details

I. General information

NPI: 1639171242
Provider Name (Legal Business Name): ANDREA L IANNUZZELLI DO, FACOI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1474 TANYARD ROAD SUITE C100
SEWELL NJ
08080
US

IV. Provider business mailing address

1474 TANYARD ROAD SUITE C100
SEWELL NJ
08080
US

V. Phone/Fax

Practice location:
  • Phone: 855-932-7476
  • Fax: 856-566-6384
Mailing address:
  • Phone: 855-932-7476
  • Fax: 856-566-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MB06796400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MA06796400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MB06796400
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA06796400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: