Healthcare Provider Details

I. General information

NPI: 1225677164
Provider Name (Legal Business Name): JACQUELINE LISSETTE MEJIA LOPEZ SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

2925 W 80TH ST APT 224
HIALEAH FL
33018-3835
US

IV. Provider business mailing address

2925 W 80TH ST APT 224
HIALEAH FL
33018-3835
US

V. Phone/Fax

Practice location:
  • Phone: 786-450-9236
  • Fax:
Mailing address:
  • Phone: 786-450-9236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number19-486
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: