Healthcare Provider Details

I. General information

NPI: 1013852979
Provider Name (Legal Business Name): ALEXIS P LUCERO CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

IV. Provider business mailing address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-5172
  • Fax:
Mailing address:
  • Phone: 505-397-5172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberG-2036
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: