Healthcare Provider Details

I. General information

NPI: 1841978814
Provider Name (Legal Business Name): CORDELLE ANDARIO LUCES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 BENTWOOD DR APT 12
WATERBURY CT
06705-3617
US

IV. Provider business mailing address

71 BENTWOOD DR APT 12
WATERBURY CT
06705-3617
US

V. Phone/Fax

Practice location:
  • Phone: 646-750-1044
  • Fax:
Mailing address:
  • Phone: 646-750-1044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number433727
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number17445
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number751964
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number160306
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: