Provider Demographics
NPI:1811294697
Name:LUCERO, NISSA BREANN (NP-C)
Entity type:Individual
Prefix:MRS
First Name:NISSA
Middle Name:BREANN
Last Name:LUCERO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1439
Mailing Address - Country:US
Mailing Address - Phone:801-798-9700
Mailing Address - Fax:801-798-3131
Practice Address - Street 1:415 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1439
Practice Address - Country:US
Practice Address - Phone:801-798-9700
Practice Address - Fax:801-798-3131
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT64501484405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily