Provider Demographics
NPI:1629632930
Name:LUCERO, KASSANDRA
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
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:PO BOX 35014
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-5014
Mailing Address - Country:US
Mailing Address - Phone:505-554-3057
Mailing Address - Fax:
Practice Address - Street 1:4118 CENTRAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1177
Practice Address - Country:US
Practice Address - Phone:505-554-3057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator