Healthcare Provider Details

I. General information

NPI: 1689702888
Provider Name (Legal Business Name): BRENDA LOU LIVENGOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6216 W GLENDALE AVE
GLENDALE AZ
85301-2308
US

IV. Provider business mailing address

10955 N 79TH AVE LOT 99
PEORIA AZ
85345-5974
US

V. Phone/Fax

Practice location:
  • Phone: 623-435-6230
  • Fax: 623-435-6270
Mailing address:
  • Phone: 623-435-6203
  • Fax: 623-435-6270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number089041
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: