Provider Demographics
NPI:1912337767
Name:IENNACO, JOANNE MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:MARIE
Last Name:IENNACO
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 1:15 LITTLE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2031
Mailing Address - Country:US
Mailing Address - Phone:203-318-1574
Mailing Address - Fax:
Practice Address - Street 1:1090 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3716
Practice Address - Country:US
Practice Address - Phone:203-285-5399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4459364SP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health