Provider Demographics
NPI:1760232789
Name:THEAGENE, GENIESE
Entity Type:Individual
Prefix:
First Name:GENIESE
Middle Name:
Last Name:THEAGENE
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 1:80 BARR LN # 80
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-4939
Mailing Address - Country:US
Mailing Address - Phone:845-709-3672
Mailing Address - Fax:
Practice Address - Street 1:80 BARR LN # 80
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4939
Practice Address - Country:US
Practice Address - Phone:845-709-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349538-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse