Provider Demographics
NPI:1306310107
Name:GENAO, RAISA
Entity type:Individual
Prefix:
First Name:RAISA
Middle Name:
Last Name:GENAO
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 1:936 BARCARMIL WAY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-0903
Mailing Address - Country:US
Mailing Address - Phone:239-265-3391
Mailing Address - Fax:239-310-2035
Practice Address - Street 1:936 BARCARMIL WAY
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-0903
Practice Address - Country:US
Practice Address - Phone:239-265-3391
Practice Address - Fax:239-310-2035
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9330481363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0JEOMOtherBCBS
FL103999800Medicaid