Healthcare Provider Details

I. General information

NPI: 1609527217
Provider Name (Legal Business Name): MARK LUCERO APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 SE DIXIE HWY
STUART FL
34994-3045
US

IV. Provider business mailing address

3124 US HIGHWAY 441 SE APT I7
OKEECHOBEE FL
34974-6836
US

V. Phone/Fax

Practice location:
  • Phone: 772-210-6429
  • Fax:
Mailing address:
  • Phone: 954-516-4761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11017381
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: