Healthcare Provider Details

I. General information

NPI: 1093113722
Provider Name (Legal Business Name): COURTNEY LOUISE LIVELY-MANYAM CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY LOUISE LIVELY CRNA

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 E 3RD ST # C-235
CHATTANOOGA TN
37403-2147
US

IV. Provider business mailing address

975 E 3RD ST # C-235
CHATTANOOGA TN
37403-2147
US

V. Phone/Fax

Practice location:
  • Phone: 814-243-0562
  • Fax:
Mailing address:
  • Phone: 814-243-0562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN607077
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN407225
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number20779
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: