Healthcare Provider Details

I. General information

NPI: 1366502304
Provider Name (Legal Business Name): SUSAN C IANNICCA CNP, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/02/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 SEASONS RD SUITE 200
HUDSON OH
44224
US

IV. Provider business mailing address

231 SEASONS RD SUITE 200
HUDSON OH
44224
US

V. Phone/Fax

Practice location:
  • Phone: 330-650-5110
  • Fax: 330-650-5115
Mailing address:
  • Phone: 330-650-5110
  • Fax: 330-650-5115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD5059
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN286846
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP07882
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: