Healthcare Provider Details

I. General information

NPI: 1902287097
Provider Name (Legal Business Name): AMG - LIVINGSTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W MAIN ST
LIVINGSTON TN
38570-1718
US

IV. Provider business mailing address

PO BOX 973
LIVINGSTON TN
38570-0973
US

V. Phone/Fax

Practice location:
  • Phone: 931-823-5681
  • Fax: 931-823-8203
Mailing address:
  • Phone: 931-823-4016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOHNETTA TRAYLOR
Title or Position: ADMINISTRATOR
Credential:
Phone: 502-596-6063