Provider Demographics
NPI:1629667860
Name:IANNETTA, LAINA BROOKE
Entity Type:Individual
Prefix:
First Name:LAINA
Middle Name:BROOKE
Last Name:IANNETTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 HEMLOCK CT APT 214
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-1657
Mailing Address - Country:US
Mailing Address - Phone:330-410-9157
Mailing Address - Fax:
Practice Address - Street 1:18288 MALLARD CIR
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-6231
Practice Address - Country:US
Practice Address - Phone:440-364-7503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH183709323401Medicaid