Healthcare Provider Details

I. General information

NPI: 1790613560
Provider Name (Legal Business Name): TIFFANY MARIE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 PREVATT ST
EUSTIS FL
32726-6123
US

IV. Provider business mailing address

1850 PREVATT ST
EUSTIS FL
32726-6123
US

V. Phone/Fax

Practice location:
  • Phone: 352-253-2511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11045638
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: