Provider Demographics
NPI:1720258817
Name:IANNINO-RENZ, ROSE M (APRN)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:IANNINO-RENZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 CAMPBELL AVE
Mailing Address - Street 2:WEST HAVEN MEDICAL GROUP
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3774
Mailing Address - Country:US
Mailing Address - Phone:203-415-9093
Mailing Address - Fax:
Practice Address - Street 1:687 CAMPBELL AVE
Practice Address - Street 2:WEST HAVEN MEDICAL GROUP
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3774
Practice Address - Country:US
Practice Address - Phone:203-415-9093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001585363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily