Basic Information
| Provider Information | |||||||||
| NPI: | 1154375020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUSTER CALDWELL | ||||||||
| FirstName: | ETHEL | ||||||||
| MiddleName: | DARLINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LUSTER | ||||||||
| OtherFirstName: | ETHEL | ||||||||
| OtherMiddleName: | DARLINE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024895730 | ||||||||
| FaxNumber: | 5024895753 | ||||||||
| Practice Location | |||||||||
| Address1: | 870 TAYLORSVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024778888 | ||||||||
| FaxNumber: | 5024772300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 01/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3004768 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 4768P | 01 | KY | ARNP LIC# | OTHER | 000000524808 | 01 | KY | ANTHEM | OTHER | 71000363800 | 05 | KY | MEDICAID |