Provider Demographics
NPI:1366838492
Name:LUSTY, GEORGIANA DAVINE (RN)
Entity Type:Individual
Prefix:
First Name:GEORGIANA
Middle Name:DAVINE
Last Name:LUSTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JORGIE
Other - Middle Name:DAVINE
Other - Last Name:LUSTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:4913 W RENO AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-6339
Mailing Address - Country:US
Mailing Address - Phone:405-948-4900
Mailing Address - Fax:405-595-3192
Practice Address - Street 1:4913 W RENO AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-6339
Practice Address - Country:US
Practice Address - Phone:405-948-4900
Practice Address - Fax:405-595-3192
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK59156163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse