Healthcare Provider Details

I. General information

NPI: 1073204285
Provider Name (Legal Business Name): DANIEL LIVINGSTON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 CHEROKEE PROFESSIONAL PARK
MARYVILLE TN
37804-5153
US

IV. Provider business mailing address

817 MACKENZIE DR
MARYVILLE TN
37804-4946
US

V. Phone/Fax

Practice location:
  • Phone: 865-980-5200
  • Fax:
Mailing address:
  • Phone: 865-387-1236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33972
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: