Healthcare Provider Details

I. General information

NPI: 1982929543
Provider Name (Legal Business Name): PAULA LESLIE LOPEZ D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAULA LESLIE FANNING D.O.

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 N 12TH ST
GRAND JUNCTION CO
81506-2863
US

IV. Provider business mailing address

PO BOX 10700
GRAND JUNCTION CO
81502-5517
US

V. Phone/Fax

Practice location:
  • Phone: 970-243-5437
  • Fax: 970-243-7792
Mailing address:
  • Phone: 970-254-2642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0052719
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: