Healthcare Provider Details

I. General information

NPI: 1326477134
Provider Name (Legal Business Name): JUAN JOSE LOPEZ RN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6223 N 21ST DR
PHOENIX AZ
85015-1902
US

IV. Provider business mailing address

6223 N 21ST DR
PHOENIX AZ
85015-1902
US

V. Phone/Fax

Practice location:
  • Phone: 623-419-2799
  • Fax:
Mailing address:
  • Phone: 623-419-2799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP7356
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN172210
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: