Provider Demographics
NPI:1942762844
Name:LISTER, DONNELLE D
Entity Type:Individual
Prefix:
First Name:DONNELLE
Middle Name:D
Last Name:LISTER
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 1:433 NW 25TH ST APT 11
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-1528
Mailing Address - Country:US
Mailing Address - Phone:580-682-1714
Mailing Address - Fax:
Practice Address - Street 1:4605 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73122-5009
Practice Address - Country:US
Practice Address - Phone:405-498-3341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management