Healthcare Provider Details

I. General information

NPI: 1205650298
Provider Name (Legal Business Name): MS. MELISSA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 E ELLIS CIR
MESA AZ
85203-5704
US

IV. Provider business mailing address

1326 E ELLIS CIR
MESA AZ
85203-5704
US

V. Phone/Fax

Practice location:
  • Phone: 760-975-2451
  • Fax:
Mailing address:
  • Phone: 760-975-2451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: