Provider Demographics
NPI:1851039341
Name:IANNOLO, MARIALENA R
Entity Type:Individual
Prefix:
First Name:MARIALENA
Middle Name:R
Last Name:IANNOLO
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 1:201 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2043
Mailing Address - Country:US
Mailing Address - Phone:631-871-0890
Mailing Address - Fax:
Practice Address - Street 1:201 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2043
Practice Address - Country:US
Practice Address - Phone:631-871-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031017235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist