Provider Demographics
NPI:1508571803
Name:LIVERMORE, TRACEY (LPN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:LIVERMORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-9297
Mailing Address - Country:US
Mailing Address - Phone:734-547-5009
Mailing Address - Fax:
Practice Address - Street 1:3250 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-9297
Practice Address - Country:US
Practice Address - Phone:734-547-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703107899164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE