Provider Demographics
NPI:1811542137
Name:LUCERO, SHANE (DNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:LUCERO
Suffix:
Gender:M
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-2770
Mailing Address - Country:US
Mailing Address - Phone:203-957-5711
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-957-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-04
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8241363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner