Healthcare Provider Details

I. General information

NPI: 1053275586
Provider Name (Legal Business Name): ANGELICA LOPEZ MACEN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 PATRIOT DR STE F
MOORPARK CA
93021-3353
US

IV. Provider business mailing address

885 PATRIOT DR STE F
MOORPARK CA
93021-3353
US

V. Phone/Fax

Practice location:
  • Phone: 805-334-1371
  • Fax:
Mailing address:
  • Phone: 805-334-1371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95037866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: