Provider Demographics
NPI:1346647674
Name:LIVERMONT, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:LIVERMONT
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 1:711 VASSAR WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3203
Mailing Address - Country:US
Mailing Address - Phone:208-542-0863
Mailing Address - Fax:
Practice Address - Street 1:711 VASSAR WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3203
Practice Address - Country:US
Practice Address - Phone:208-542-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID$$$$$$$$$Medicaid