Provider Demographics
NPI:1679710149
Name:IANNAZZO, KELLY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:IANNAZZO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 CELEBRATION PL
Mailing Address - Street 2:SUITE A280
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-4970
Mailing Address - Country:US
Mailing Address - Phone:407-566-4411
Mailing Address - Fax:407-566-4416
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:SUITE A280
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-566-4411
Practice Address - Fax:407-566-4416
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053583363A00000X
SC1886363A00000X
FLPA 9108977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant