Provider Demographics
NPI:1508802547
Name:LIVINGSTONE, COLLEEN ADRIS (NP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ADRIS
Last Name:LIVINGSTONE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S. HUNTINGTON AVE
Mailing Address - Street 2:(111) HO
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4893
Mailing Address - Country:US
Mailing Address - Phone:857-364-2471
Mailing Address - Fax:857-364-4343
Practice Address - Street 1:150 S. HUNTINGTON AVE
Practice Address - Street 2:(111) HO
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4893
Practice Address - Country:US
Practice Address - Phone:857-364-2471
Practice Address - Fax:857-364-4343
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC65316207RH0003X
MARN196643363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
019996M65Medicare PIN
Q73006Medicare UPIN