Healthcare Provider Details

I. General information

NPI: 1114702123
Provider Name (Legal Business Name): JESSICA MICHELLE LOPES CAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 W UNDERWOOD ST
ORLANDO FL
32806-1110
US

IV. Provider business mailing address

2465 WESTMONT LN
ROYAL PALM BEACH FL
33411-6137
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-5111
  • Fax:
Mailing address:
  • Phone: 561-254-1041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA875
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: