Provider Demographics
NPI:1730659285
Name:LUCERO, TAMMY R
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:R
Last Name:LUCERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:R
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4258
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NM
Mailing Address - Zip Code:87533-4258
Mailing Address - Country:US
Mailing Address - Phone:505-699-5814
Mailing Address - Fax:
Practice Address - Street 1:1501 E FAIRVIEW LN
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2846
Practice Address - Country:US
Practice Address - Phone:505-699-5814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist