Provider Demographics
NPI:1902879554
Name:IANNARELLI, JENNIFER MYLES (OD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MYLES
Last Name:IANNARELLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1400 HAND AVE STE N
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8196
Mailing Address - Country:US
Mailing Address - Phone:386-872-3111
Mailing Address - Fax:386-872-3190
Practice Address - Street 1:1400 HAND AVE STE N
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8196
Practice Address - Country:US
Practice Address - Phone:386-872-3111
Practice Address - Fax:386-872-3190
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620993900Medicaid
FLV02638Medicare UPIN
FL620993900Medicaid