Provider Demographics
NPI:1760682959
Name:GENOVESE, LYDIA P (RD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:P
Last Name:GENOVESE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12964 W FOSSIL DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-5176
Mailing Address - Country:US
Mailing Address - Phone:317-694-3986
Mailing Address - Fax:317-630-2478
Practice Address - Street 1:12964 W FOSSIL DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-5176
Practice Address - Country:US
Practice Address - Phone:317-694-3986
Practice Address - Fax:765-675-8257
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001065A133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered