Healthcare Provider Details

I. General information

NPI: 1639947971
Provider Name (Legal Business Name): JAIMIE LOPEZ RDN, IBCLC, NBC-HWC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 04/21/2024
Certification Date: 04/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S 3RD ST
MONTROSE CO
81401-4212
US

IV. Provider business mailing address

800 S 3RD ST
MONTROSE CO
81401-4212
US

V. Phone/Fax

Practice location:
  • Phone: 970-240-7280
  • Fax:
Mailing address:
  • Phone: 970-240-7280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1049743
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-49587
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number354335640
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: