Provider Demographics
NPI:1609383090
Name:LUCERO, NICOLE CHAVEZ (COTA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:CHAVEZ
Last Name:LUCERO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4688 RIMROCK DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-5061
Mailing Address - Country:US
Mailing Address - Phone:575-621-0545
Mailing Address - Fax:
Practice Address - Street 1:1350 HILLRISE CIR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4759
Practice Address - Country:US
Practice Address - Phone:575-522-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-07
Last Update Date:2018-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3684224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant