Provider Demographics
NPI:1164143152
Name:LIVINGSTON, MATTIE MITCHELL
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:MITCHELL
Last Name:LIVINGSTON
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 1:112 STROMAN WAY
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2532
Mailing Address - Country:US
Mailing Address - Phone:478-397-4327
Mailing Address - Fax:
Practice Address - Street 1:112 STROMAN WAY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-2532
Practice Address - Country:US
Practice Address - Phone:478-397-4327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN287690363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health