Provider Demographics
NPI:1497232284
Name:IANNAZZO, BRIANA NICOLE (DCS, BST)
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:NICOLE
Last Name:IANNAZZO
Suffix:
Gender:F
Credentials:DCS, BST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 W CRAIG RD STE 180
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-0861
Mailing Address - Country:US
Mailing Address - Phone:702-586-5999
Mailing Address - Fax:702-586-5991
Practice Address - Street 1:3131 W CRAIG RD STE 180
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-0861
Practice Address - Country:US
Practice Address - Phone:702-586-5999
Practice Address - Fax:702-586-5991
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1578935508Medicaid