Provider Demographics
NPI:1992083547
Name:FORD, LISTINA (LPN)
Entity type:Individual
Prefix:
First Name:LISTINA
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4819
Mailing Address - Country:US
Mailing Address - Phone:405-471-7670
Mailing Address - Fax:
Practice Address - Street 1:4149 HIGHLINE BLVD
Practice Address - Street 2:SUITE 380
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73108-2103
Practice Address - Country:US
Practice Address - Phone:405-942-7650
Practice Address - Fax:405-942-7686
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK50218164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid