Provider Demographics
NPI:1346262250
Name:LIVADITIS, FANNIE (LMT)
Entity Type:Individual
Prefix:MS
First Name:FANNIE
Middle Name:
Last Name:LIVADITIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1082 KIRKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1911
Mailing Address - Country:US
Mailing Address - Phone:612-578-5443
Mailing Address - Fax:
Practice Address - Street 1:2920 BRYANT AVE S
Practice Address - Street 2:SUITE 102
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2195
Practice Address - Country:US
Practice Address - Phone:612-578-5443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist