Provider Demographics
NPI:1245982891
Name:LIVELY, MARIE KRIDER (PNP-PC)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:KRIDER
Last Name:LIVELY
Suffix:
Gender:F
Credentials:PNP-PC
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:NICOLE
Other - Last Name:KRIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3117 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3349
Mailing Address - Country:US
Mailing Address - Phone:804-212-8870
Mailing Address - Fax:
Practice Address - Street 1:635 N NC 16 BUSINESS HWY
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-7574
Practice Address - Country:US
Practice Address - Phone:704-489-8401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015657363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics