Healthcare Provider Details

I. General information

NPI: 1972946507
Provider Name (Legal Business Name): AUDREY CAROLINE SAMELSON LIVESEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2013
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 BARB ST
SILVERDALE WA
98315-2050
US

IV. Provider business mailing address

2050 BARB ST
SILVERDALE WA
98315-2050
US

V. Phone/Fax

Practice location:
  • Phone: 360-315-4365
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number28115
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: