Healthcare Provider Details

I. General information

NPI: 1972102192
Provider Name (Legal Business Name): IVONNE ILEANA JACOMINO LOPEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4661 W 8TH LN
HIALEAH FL
33012-3517
US

IV. Provider business mailing address

4661 W 8TH LN
HIALEAH FL
33012-3517
US

V. Phone/Fax

Practice location:
  • Phone: 786-728-0785
  • Fax:
Mailing address:
  • Phone: 786-728-0785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9342058
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11009290
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: