Provider Demographics
NPI:1649556911
Name:LISTER, SHAWNDA
Entity Type:Individual
Prefix:
First Name:SHAWNDA
Middle Name:
Last Name:LISTER
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 1:21228 MEADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:HOWE
Mailing Address - State:OK
Mailing Address - Zip Code:74940-2008
Mailing Address - Country:US
Mailing Address - Phone:918-658-2189
Mailing Address - Fax:918-658-2180
Practice Address - Street 1:21228 MEADOWBROOK LN
Practice Address - Street 2:
Practice Address - City:HOWE
Practice Address - State:OK
Practice Address - Zip Code:74940-2008
Practice Address - Country:US
Practice Address - Phone:918-658-2189
Practice Address - Fax:918-658-2180
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator