Provider Demographics
NPI:1275373540
Name:LIVINGSTON, KRYSTAL TANESHIA
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:TANESHIA
Last Name:LIVINGSTON
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 1:145 WILLOW BAY DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 WILLOW BAY DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2843
Practice Address - Country:US
Practice Address - Phone:803-378-6213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-25
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC257780163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical