Provider Demographics
NPI:1730378506
Name:COSTON, LISETTE A (RD, LD, MBA)
Entity type:Individual
Prefix:MRS
First Name:LISETTE
Middle Name:A
Last Name:COSTON
Suffix:
Gender:F
Credentials:RD, LD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10132 S HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-6008
Mailing Address - Country:US
Mailing Address - Phone:918-298-6307
Mailing Address - Fax:
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-7208
Practice Address - Fax:918-494-7270
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD810133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered