Provider Demographics
NPI:1407038151
Name:LIVENGOOD, TAMELLA PAIGE (MSN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:TAMELLA
Middle Name:PAIGE
Last Name:LIVENGOOD
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4977 SKYVIEW CT
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-6941
Mailing Address - Country:US
Mailing Address - Phone:231-486-5516
Mailing Address - Fax:231-421-1439
Practice Address - Street 1:4977 SKYVIEW CT
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6941
Practice Address - Country:US
Practice Address - Phone:231-486-5516
Practice Address - Fax:231-421-1439
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704197389363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1407038151Medicaid