Healthcare Provider Details

I. General information

NPI: 1841993508
Provider Name (Legal Business Name): DAIQUIRI ANN LOPEZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17240 CORTEZ BLVD
BROOKSVILLE FL
34601-8921
US

IV. Provider business mailing address

10065 CORTEZ BLVD
WEEKI WACHEE FL
34613-6389
US

V. Phone/Fax

Practice location:
  • Phone: 352-796-5111
  • Fax:
Mailing address:
  • Phone: 352-596-4660
  • Fax: 352-596-4674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11025368
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: