Provider Demographics
NPI:1417359910
Name:LUNSFORD, SHANE LYNN
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:LYNN
Last Name:LUNSFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 SW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73108-7802
Mailing Address - Country:US
Mailing Address - Phone:140-590-5336
Mailing Address - Fax:
Practice Address - Street 1:1320 SW 24TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73108-7802
Practice Address - Country:US
Practice Address - Phone:140-590-5336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist