Healthcare Provider Details

I. General information

NPI: 1417626581
Provider Name (Legal Business Name): HEALTHY LIVING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 N GERMANTOWN PKWY STE 101-491
CORDOVA TN
38016-5872
US

IV. Provider business mailing address

1138 N GERMANTOWN PKWY STE 101-491
CORDOVA TN
38016-5872
US

V. Phone/Fax

Practice location:
  • Phone: 720-741-6647
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierNPI
Identifier TypeOTHER
Identifier StateCA
Identifier Issuer1689235525

VIII. Authorized Official

Name: THANH NGUYEN
Title or Position: CEO
Credential:
Phone: 720-741-6647