Provider Demographics
NPI:1013415637
Name:LUCERO, MELANIE J
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:J
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 1:128 STALLION CIR
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4454
Mailing Address - Country:US
Mailing Address - Phone:575-418-1094
Mailing Address - Fax:
Practice Address - Street 1:415 PARK ST
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4543
Practice Address - Country:US
Practice Address - Phone:575-838-7614
Practice Address - Fax:575-838-0508
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42721733Medicaid