Provider Demographics
NPI:1467985341
Name:LIVESEY, MARIE NICHOLE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:NICHOLE
Last Name:LIVESEY
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 1:100 BREWSTER BLVD
Mailing Address - Street 2:NAVAL HOSPITAL CAMP LEJEUNE ATTN: GME
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:NAVAL HOSPITAL CAMP LEJEUNE ATTN: GME
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:910-450-3138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01081198A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine