Healthcare Provider Details

I. General information

NPI: 1326496597
Provider Name (Legal Business Name): JENNIFER LEANNE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2016
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12010 S WARNER ELLIOT LOOP
PHOENIX AZ
85044-2731
US

IV. Provider business mailing address

PO BOX 9415
CHANDLER HEIGHTS AZ
85127-9415
US

V. Phone/Fax

Practice location:
  • Phone: 480-961-2366
  • Fax:
Mailing address:
  • Phone: 480-532-8241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN120668
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: