Provider Demographics
NPI:1194223677
Name:DIVERSE NP IN FAMILY ADULT HEALTH AND GERONTOLOGY, PLLC
Entity Type:Organization
Organization Name:DIVERSE NP IN FAMILY ADULT HEALTH AND GERONTOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVSHITS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:718-629-8133
Mailing Address - Street 1:2844 OCEAN PKWY STE 6
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-7900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2844 OCEAN PKWY STE 6
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7900
Practice Address - Country:US
Practice Address - Phone:718-629-8133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty