Provider Demographics
NPI:1033239678
Name:LIVELY, PEGGY YVONNE (ARNP)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:YVONNE
Last Name:LIVELY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 SHELL CT
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-4630
Mailing Address - Country:US
Mailing Address - Phone:954-895-0222
Mailing Address - Fax:
Practice Address - Street 1:1120 GLENNS BAY RD
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-4757
Practice Address - Country:US
Practice Address - Phone:843-215-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1563Medicaid
SCAA4703Medicare UPIN
SCNP1563Medicaid