Provider Demographics
NPI:1114472800
Name:LIVESAY, MICHELLE (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LIVESAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 W C ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2367
Mailing Address - Country:US
Mailing Address - Phone:918-409-0157
Mailing Address - Fax:918-209-4788
Practice Address - Street 1:1911 W C ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2367
Practice Address - Country:US
Practice Address - Phone:918-409-0157
Practice Address - Fax:918-209-4788
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1499133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered