Healthcare Provider Details

I. General information

NPI: 1215230214
Provider Name (Legal Business Name): GINA E LOPEZ M.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 CONNER LN
KISSIMMEE FL
34741-7723
US

IV. Provider business mailing address

2825 WAGON WHEEL TRL
SAINT CLOUD FL
34772-8985
US

V. Phone/Fax

Practice location:
  • Phone: 321-948-9907
  • Fax:
Mailing address:
  • Phone: 321-948-9907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: