Provider Demographics
NPI:1194520429
Name:LIVELY, TILLIE JOY
Entity type:Individual
Prefix:
First Name:TILLIE
Middle Name:JOY
Last Name:LIVELY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 FAIRLEA PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-9587
Mailing Address - Country:US
Mailing Address - Phone:304-956-0248
Mailing Address - Fax:
Practice Address - Street 1:205 FAIRLEA PLAZA DR
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-9587
Practice Address - Country:US
Practice Address - Phone:304-956-0248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant