Healthcare Provider Details

I. General information

NPI: 1790602076
Provider Name (Legal Business Name): MISS JESSICA MAAYAN LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9231 W OLYMPIC BLVD
BEVERLY HILLS CA
90212-4658
US

IV. Provider business mailing address

13525 PALA AVE
SYLMAR CA
91342-1160
US

V. Phone/Fax

Practice location:
  • Phone: 310-275-5400
  • Fax:
Mailing address:
  • Phone: 818-519-3275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95040290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: