Healthcare Provider Details

I. General information

NPI: 1700635406
Provider Name (Legal Business Name): MISS ERICA AMANDA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41550 ECLECTIC ST
PALM DESERT CA
92260-1967
US

IV. Provider business mailing address

1774 ZONAL AVE BLDG C
LOS ANGELES CA
90033-1064
US

V. Phone/Fax

Practice location:
  • Phone: 760-609-7876
  • Fax:
Mailing address:
  • Phone: 310-221-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: