Provider Demographics
NPI:1124559489
Name:LUCERO, NICOLE ANNE (RD)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANNE
Last Name:LUCERO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15509 STARLING WATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547
Mailing Address - Country:US
Mailing Address - Phone:813-503-5825
Mailing Address - Fax:
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:LAKELAND REGIONAL HEALTH DIABETES DEPT.
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-687-1100
Practice Address - Fax:863-687-1412
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
866014133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered