Healthcare Provider Details

I. General information

NPI: 1417836347
Provider Name (Legal Business Name): KATY G LOPEZ PAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 KINGSLEY AVE STE 300
ORANGE PARK FL
32073-4898
US

IV. Provider business mailing address

330 CORPORATE WAY STE 200
ORANGE PARK FL
32073-6214
US

V. Phone/Fax

Practice location:
  • Phone: 904-621-0643
  • Fax: 833-576-2330
Mailing address:
  • Phone: 904-282-6331
  • Fax: 904-866-4818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPRN11041910
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11041910
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: