Provider Demographics
NPI:1063781714
Name:LIVELY, SALLIE H (NP)
Entity type:Individual
Prefix:
First Name:SALLIE
Middle Name:H
Last Name:LIVELY
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:117 W SEVIER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3799
Practice Address - Country:US
Practice Address - Phone:423-224-3300
Practice Address - Fax:423-378-5324
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2015-04-20
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Provider Licenses
StateLicense IDTaxonomies
VA0024169711363LF0000X
TN16259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10350O5749Medicare PIN
VAVV4743B288Medicare PIN