Basic Information
| Provider Information | |||||||||
| NPI: | 1265745137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIVELY | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RD LD CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CYNDEE CIR | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309071338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067330188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 FREEDOM WAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309046258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067330118 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2010 | ||||||||
| LastUpdateDate: | 07/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD002057 | GA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.