Provider Demographics
NPI:1689287641
Name:GENNIE, LYDIA (LPN)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:GENNIE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39817-8393
Mailing Address - Country:US
Mailing Address - Phone:850-363-8735
Mailing Address - Fax:
Practice Address - Street 1:1004 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39817-8393
Practice Address - Country:US
Practice Address - Phone:850-363-8735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5214585164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse