Provider Demographics
NPI:1942509294
Name:DE GENNARO, ALYSSA MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:ALYSSA
Middle Name:MARIE
Last Name:DE GENNARO
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 1:103 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-3901
Mailing Address - Country:US
Mailing Address - Phone:631-682-9504
Mailing Address - Fax:
Practice Address - Street 1:103 MADISON ST
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-3901
Practice Address - Country:US
Practice Address - Phone:631-682-9504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304428-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse