Healthcare Provider Details

I. General information

NPI: 1629995253
Provider Name (Legal Business Name): MALLORY LYNN LIVENGOOD DNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY LYNN GORE

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 SAINT MARY RD STE 303
VALPARAISO IN
46383-3986
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-286-3832
  • Fax: 219-703-6935
Mailing address:
  • Phone: 219-392-7084
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28236571A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: