Provider Demographics
NPI:1164987764
Name:GENNARO, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:GENNARO
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 1:24239 GRANITE POINT CT
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE
Mailing Address - State:SD
Mailing Address - Zip Code:57751-6673
Mailing Address - Country:US
Mailing Address - Phone:402-680-3889
Mailing Address - Fax:
Practice Address - Street 1:24239 GRANITE POINT CT
Practice Address - Street 2:
Practice Address - City:KEYSTONE
Practice Address - State:SD
Practice Address - Zip Code:57751-6673
Practice Address - Country:US
Practice Address - Phone:402-680-3889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171WH0202X, 253Z00000X, 332BP3500X
SD332B00000X, 374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No171WH0202XOther Service ProvidersContractorHome Modifications
No253Z00000XAgenciesIn Home Supportive Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No374U00000XNursing Service Related ProvidersHome Health Aide