Provider Demographics
NPI:1780871020
Name:IANNAZZO, KEVIN J (CO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:IANNAZZO
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 S TONOPAH DR STE 120
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4044
Mailing Address - Country:US
Mailing Address - Phone:702-336-9681
Mailing Address - Fax:
Practice Address - Street 1:526 S TONOPAH DR STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4044
Practice Address - Country:US
Practice Address - Phone:702-336-9681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist