Healthcare Provider Details

I. General information

NPI: 1366389942
Provider Name (Legal Business Name): WANDA ROSARIO LOPEZ PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 NW 64TH TER STE A
GAINESVILLE FL
32605-4261
US

IV. Provider business mailing address

1131 NW 64TH TER STE A
GAINESVILLE FL
32605-4261
US

V. Phone/Fax

Practice location:
  • Phone: 352-363-2025
  • Fax:
Mailing address:
  • Phone: 352-363-2025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11047573
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN9513254
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: