Provider Demographics
NPI:1366502304
Name:IANNICCA, SUSAN C (CNP, RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:IANNICCA
Suffix:
Gender:F
Credentials:CNP, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 SEASONS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44224
Mailing Address - Country:US
Mailing Address - Phone:330-650-5110
Mailing Address - Fax:330-650-5115
Practice Address - Street 1:231 SEASONS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44224
Practice Address - Country:US
Practice Address - Phone:330-650-5110
Practice Address - Fax:330-650-5115
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD5059133V00000X
OHRN286846363L00000X
OHNP07882363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2598765Medicaid
OHQ06728Medicare UPIN
MT02293Medicare PIN
OH2598765Medicaid