Healthcare Provider Details

I. General information

NPI: 1609428705
Provider Name (Legal Business Name): LISSETTE LOPEZ LOPEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11750 SW 40TH ST
MIAMI FL
33175-3530
US

IV. Provider business mailing address

15590 SW 42ND LN
MIAMI FL
33185-4209
US

V. Phone/Fax

Practice location:
  • Phone: 305-223-3000
  • Fax:
Mailing address:
  • Phone: 786-390-3285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9288831
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberME107145
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: