Provider Demographics
NPI:1548882608
Name:IANNICELLI, TAYLOR MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:IANNICELLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:522 VAN SICKLEN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4613
Mailing Address - Country:US
Mailing Address - Phone:917-600-5099
Mailing Address - Fax:
Practice Address - Street 1:1 CAMPUS RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-4479
Practice Address - Country:US
Practice Address - Phone:718-390-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-07-13
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant