Provider Demographics
NPI:1194507962
Name:LIVALITY INTEGRATED HEALTH
Entity type:Organization
Organization Name:LIVALITY INTEGRATED HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYQUITTA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRIER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:706-289-2647
Mailing Address - Street 1:1075 OAKLEAF PLANTATION PKWY
Mailing Address - Street 2:SUITE 304, BOX 317
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 CORSAIR LN STE 201
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8484
Practice Address - Country:US
Practice Address - Phone:904-787-8850
Practice Address - Fax:833-740-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty