Provider Demographics
NPI:1487015376
Name:LIVINGSTON, STEFANIE TIERA (PMHNP)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:TIERA
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 SAGE MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-5996
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4039 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-3389
Practice Address - Country:US
Practice Address - Phone:770-389-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-19
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5008450363LP0808X
GARN266928363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health