Provider Demographics
NPI:1700841822
Name:IANNELLO, AMY M (PAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:IANNELLO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 862851
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-2851
Mailing Address - Country:US
Mailing Address - Phone:954-847-4273
Mailing Address - Fax:954-847-4245
Practice Address - Street 1:1600 S ANDREWS AVE
Practice Address - Street 2:ATRIUM BLDG 1ST FLOOR
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-760-7171
Practice Address - Fax:954-764-1722
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P04009Medicare UPIN
FLU3005YMedicare ID - Type Unspecified