Provider Demographics
NPI:1154375020
Name:LUSTER CALDWELL, ETHEL DARLINE (ARNP)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:DARLINE
Last Name:LUSTER CALDWELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:ETHEL
Other - Middle Name:DARLINE
Other - Last Name:LUSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:870 TAYLORSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40071
Practice Address - Country:US
Practice Address - Phone:502-477-8888
Practice Address - Fax:502-477-2300
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4768POtherARNP LIC#
KY000000524808OtherANTHEM
KY71000363800Medicaid
KY71000363800Medicaid
KY00162041Medicare PIN