Provider Demographics
NPI:1487401238
Name:IAGNOCCO, GABRIELLA
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:IAGNOCCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5781 BRIARCLIFF LN APT 9
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-7425
Mailing Address - Country:US
Mailing Address - Phone:269-903-9459
Mailing Address - Fax:
Practice Address - Street 1:5781 BRIARCLIFF LN APT 9
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-7425
Practice Address - Country:US
Practice Address - Phone:269-903-9459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10242921133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered