Basic Information
| Provider Information | |||||||||
| NPI: | 1497056642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIVINGSTON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ANP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NECZYPOR | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ANP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 781389 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409184690 | ||||||||
| FaxNumber: | 4409184694 | ||||||||
| Practice Location | |||||||||
| Address1: | 4176 STATE ROUTE 306 | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440949203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409184690 | ||||||||
| FaxNumber: | 4409184694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 11970-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 3103171 | 05 | OH | MEDICAID | RN 325805 | 01 | OH | CERTIFICATE OF AUTHORITY | OTHER |