Healthcare Provider Details

I. General information

NPI: 1053095323
Provider Name (Legal Business Name): LISA LYNN LIVINGSTON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 S LAKE DR
LEXINGTON SC
29073-7755
US

IV. Provider business mailing address

2214 OLD CHEROKEE RD
LEXINGTON SC
29072-9725
US

V. Phone/Fax

Practice location:
  • Phone: 803-520-9380
  • Fax: 803-520-5972
Mailing address:
  • Phone: 803-520-9380
  • Fax: 803-520-5972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number27494
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: