Healthcare Provider Details

I. General information

NPI: 1750075321
Provider Name (Legal Business Name): NICOLE ROSE IANNI CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 RICHMOND HILL RD
STATEN ISLAND NY
10314-5904
US

IV. Provider business mailing address

30 BROOKSIDE LOOP
STATEN ISLAND NY
10309-4501
US

V. Phone/Fax

Practice location:
  • Phone: 718-979-5678
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number032290
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: