Provider Demographics
NPI:1386017507
Name:GENOVA, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GENOVA
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 1:15 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-2921
Mailing Address - Country:US
Mailing Address - Phone:732-397-7940
Mailing Address - Fax:
Practice Address - Street 1:850 N WOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-4038
Practice Address - Country:US
Practice Address - Phone:908-925-9309
Practice Address - Fax:908-925-7910
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00600100363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health