Provider Demographics
NPI:1164987764
Name:GENNARO, LISA
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:GENNARO
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 1:1305 MADILL ST
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE
Mailing Address - State:SD
Mailing Address - Zip Code:57751-2075
Mailing Address - Country:US
Mailing Address - Phone:605-666-4149
Mailing Address - Fax:
Practice Address - Street 1:1305 MADILL ST
Practice Address - Street 2:
Practice Address - City:KEYSTONE
Practice Address - State:SD
Practice Address - Zip Code:57751-2075
Practice Address - Country:US
Practice Address - Phone:605-666-4149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD374U00000X, 251E00000X, 332B00000X, 374U00000X, 251E00000X
171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
No171WH0202XOther Service ProvidersContractorHome Modifications
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9551220Medicaid