Provider Demographics
NPI:1629729843
Name:LUCERO, KALLYN JEAN (NP)
Entity Type:Individual
Prefix:MRS
First Name:KALLYN
Middle Name:JEAN
Last Name:LUCERO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 N CLEAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-9499
Mailing Address - Country:US
Mailing Address - Phone:989-891-6840
Mailing Address - Fax:
Practice Address - Street 1:3009 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4555
Practice Address - Country:US
Practice Address - Phone:989-633-1350
Practice Address - Fax:989-633-1355
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286472363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner