Provider Demographics
NPI:1760074280
Name:GANGEMI, LISA MARIE (MS, RDN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:GANGEMI
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-3011
Mailing Address - Country:US
Mailing Address - Phone:646-460-7129
Mailing Address - Fax:
Practice Address - Street 1:100 FOSTER RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3011
Practice Address - Country:US
Practice Address - Phone:646-460-7129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty