=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043617087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALLYSON LUCERO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2014
-----------------------------------------------------
Last Update Date | 01/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9977 WOODS DR
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-364-5573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9977 WOODS DR
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-364-5573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 209012089
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------