Provider Demographics
NPI:1093113722
Name:LIVELY-MANYAM, COURTNEY LOUISE (CRNA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LOUISE
Last Name:LIVELY-MANYAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LOUISE
Other - Last Name:LIVELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:975 E 3RD ST # C-235
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2147
Mailing Address - Country:US
Mailing Address - Phone:814-243-0562
Mailing Address - Fax:
Practice Address - Street 1:975 E 3RD ST # C-235
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:814-243-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN607077367500000X
OHRN407225367500000X
TN20779367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered