Provider Demographics
NPI:1376869263
Name:MARSHALL, LYVETTA WALKER (SPECIALIST)
Entity Type:Individual
Prefix:MRS
First Name:LYVETTA
Middle Name:WALKER
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3781 FREEMAN DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9578
Mailing Address - Country:US
Mailing Address - Phone:706-495-6166
Mailing Address - Fax:
Practice Address - Street 1:187 HIGHTOWER DR
Practice Address - Street 2:SUITE B
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-8405
Practice Address - Country:US
Practice Address - Phone:706-823-9973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO072859225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter