Provider Demographics
NPI:1194214973
Name:LUSTER, FENNETTA MARIA (RN)
Entity Type:Individual
Prefix:
First Name:FENNETTA
Middle Name:MARIA
Last Name:LUSTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 MOISELLE ST
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4920
Mailing Address - Country:US
Mailing Address - Phone:405-613-2949
Mailing Address - Fax:405-613-2949
Practice Address - Street 1:4300 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5107
Practice Address - Country:US
Practice Address - Phone:405-613-2949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0097608163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse