Provider Demographics
NPI:1265498646
Name:LIVELY, TERSA L (DO)
Entity Type:Individual
Prefix:DR
First Name:TERSA
Middle Name:L
Last Name:LIVELY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:705 MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:OLIVER SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37840-1761
Mailing Address - Country:US
Mailing Address - Phone:865-280-1466
Mailing Address - Fax:865-280-1469
Practice Address - Street 1:705 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:OLIVER SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37840-1761
Practice Address - Country:US
Practice Address - Phone:865-280-1466
Practice Address - Fax:865-280-1469
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO0000001321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3306430Medicaid
TN3306430Medicaid
H19472Medicare UPIN