Provider Demographics
NPI:1972946507
Name:LIVESEY, AUDREY (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:LIVESEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 558
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96375-0043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 KOWAN
Practice Address - Street 2:
Practice Address - City:URASOE
Practice Address - State:OKINAWA
Practice Address - Zip Code:901-2124
Practice Address - Country:JP
Practice Address - Phone:315-637-3154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-13
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE28115207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty