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General NPI Number Information
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NPI Number | 1609229798
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Entity Type | Individual
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Provider Name | JENNA MARIE IANNUCCILLI M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/13/2016
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Last Update Date | 01/19/2021
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Provider Practice Location Address
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Address Line | 400 MASSASOIT AVE STE 300
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City | EAST PROVIDENCE
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State | RI
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Zip | 02914-2012
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Country | US
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Telephone | 401-434-2704
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Fax | 401-434-4054
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Provider Business Mailing Address
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Address Line | 825 CHALKSTONE AVE
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City | PROVIDENCE
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State | RI
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Zip | 02908-4728
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | LP03816
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License Number State | RI
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MD16838
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License Number State | RI
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