Provider Demographics
NPI:1689702888
Name:LIVENGOOD, BRENDA LOU
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LOU
Last Name:LIVENGOOD
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 1:10955 N 79TH AVE LOT 99
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-5974
Mailing Address - Country:US
Mailing Address - Phone:623-435-6203
Mailing Address - Fax:623-435-6270
Practice Address - Street 1:6216 W GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2308
Practice Address - Country:US
Practice Address - Phone:623-435-6230
Practice Address - Fax:623-435-6270
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ089041163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ920076Medicaid