Provider Demographics
NPI:1144335357
Name:IACONO, NANCY B (OD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:B
Last Name:IACONO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BARBARA DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-4345
Mailing Address - Country:US
Mailing Address - Phone:401-253-2268
Mailing Address - Fax:
Practice Address - Street 1:375 METACOM AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-5179
Practice Address - Country:US
Practice Address - Phone:401-253-2020
Practice Address - Fax:401-253-3220
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00504152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RINB07827Medicaid
RI007003239Medicare PIN
RINB07827Medicaid