Provider Demographics
NPI:1881165132
Name:LIVELY, BRIANNA KATHLEEN
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:KATHLEEN
Last Name:LIVELY
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 1:120 EAST DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-1640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 EAST DR
Practice Address - Street 2:
Practice Address - City:NORTH MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-1640
Practice Address - Country:US
Practice Address - Phone:516-473-6639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist