Basic Information
| Provider Information | |||||||||
| NPI: | 1629729843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCERO | ||||||||
| FirstName: | KALLYN | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1180 N CLEAR LAKE RD | ||||||||
| Address2: | |||||||||
| City: | WEST BRANCH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486619499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898916840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3009 N SAGINAW RD | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486404555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896331350 | ||||||||
| FaxNumber: | 9896331355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2022 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704286472 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.