Provider Demographics
NPI:1679796197
Name:REILLY, GENEVIEVE CATHERINE (NP)
Entity Type:Individual
Prefix:MS
First Name:GENEVIEVE
Middle Name:CATHERINE
Last Name:REILLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W 168TH ST
Mailing Address - Street 2:BOX 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:212-342-5155
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST FL 14 RM 104
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-7771
Practice Address - Fax:212-342-5382
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332048363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01913395Medicaid
NYS79154Medicare UPIN