Healthcare Provider Details

I. General information

NPI: 1811444110
Provider Name (Legal Business Name): NICOLE MARIE YORDAN LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14000 FIVAY RD
HUDSON FL
34667-7103
US

IV. Provider business mailing address

4225 BONFIRE DR
ODESSA FL
33556-4607
US

V. Phone/Fax

Practice location:
  • Phone: 727-819-2929
  • Fax:
Mailing address:
  • Phone: 787-324-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME169234
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: