Basic Information
| Provider Information | |||||||||
| NPI: | 1619963345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IANNONE | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3155 N POINT PKWY | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT, BUILDING F, SUITE 100 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1364 CLIFTON RD NE | ||||||||
| Address2: | STE B3 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 05/10/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN079102 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000550503A | 05 | GA | MEDICAID | 000550503B | 05 | GA | MEDICAID |