Provider Demographics
NPI:1649269309
Name:IANNACO, DOROTHY (APN)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:IANNACO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 CRAWFORD PL STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3954
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:239 HURFFVILLE CROSSKEYS RD STE 160
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-4005
Practice Address - Country:US
Practice Address - Phone:856-341-8200
Practice Address - Fax:856-341-8215
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00048000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0055441Medicaid
NJ087047XVAMedicare UPIN
NJ0055441Medicaid
NJ087047YBAWMedicare PIN