=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013571652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA LUCERO FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2019
-----------------------------------------------------
Last Update Date | 08/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9897 W MCDOWELL RD STE 100
-----------------------------------------------------
City | TOLLESON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85353-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-474-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22269 W MOONLIGHT PATH
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85326-8591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-388-4754
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 224620
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------