Provider Demographics
NPI:1851042808
Name:LIVINGSTON, ELLIE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8520 HAWKS NEST DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-5330
Mailing Address - Country:US
Mailing Address - Phone:205-454-9899
Mailing Address - Fax:
Practice Address - Street 1:8520 HAWKS NEST DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76131-5330
Practice Address - Country:US
Practice Address - Phone:205-454-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3348133V00000X
FLND10909133V00000X
TN4129133V00000X
MO2021038779133V00000X
GALD005975133V00000X
TXDT86715133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered