Provider Demographics
NPI:1114415718
Name:LUCAS, DIANE JANEAN
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:JANEAN
Last Name:LUCAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 NW 41ST ST APT 27
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-6291
Mailing Address - Country:US
Mailing Address - Phone:405-968-5074
Mailing Address - Fax:
Practice Address - Street 1:3016 NW 41ST ST APT 27
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6291
Practice Address - Country:US
Practice Address - Phone:405-968-5074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-29
Last Update Date:2018-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK04141417OtherHEALTHCHOICE