MEDICARE: DIANE JANEAN LUCAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04141417	OTHER	OK	HEALTHCHOICE

General Provider Information

NPI Number	:	1114415718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE JANEAN LUCAS

Provider Business Mailing Address
First Line	:	3016 NW 41ST ST APT 27
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-6291
Country	:	US
Telephone Number	:	405-968-5074
Fax Number	:

Provider Business Practice Location Address
First Line	:	3016 NW 41ST ST APT 27
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-6291
Country	:	US
Telephone Number	:	405-968-5074
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2018
Last Update Date	:	04/29/2018

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