Provider Demographics
NPI:1114261401
Name:LIVELY, MARY MICHELLE (NP-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MICHELLE
Last Name:LIVELY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8198 WALNUT HILL LN STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4316
Mailing Address - Country:US
Mailing Address - Phone:214-345-4449
Mailing Address - Fax:214-345-1238
Practice Address - Street 1:8198 WALNUT HILL LN STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4316
Practice Address - Country:US
Practice Address - Phone:214-345-4449
Practice Address - Fax:214-345-1238
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP122051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8543NHOtherBCBS TX
TX338206102Medicaid
TX338206103Medicaid
TX338206103Medicaid
TX276722YK9HMedicare PIN
TX276722YK8AMedicare PIN
TX276722YKQLMedicare PIN