Provider Demographics
NPI:1568010791
Name:LUCERO, NICOLE JOHANNA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JOHANNA
Last Name:LUCERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 OAK ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2919
Mailing Address - Country:US
Mailing Address - Phone:631-578-5079
Mailing Address - Fax:
Practice Address - Street 1:292 OAK ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2919
Practice Address - Country:US
Practice Address - Phone:631-578-5079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program