Healthcare Provider Details

I. General information

NPI: 1013722115
Provider Name (Legal Business Name): TAYLOR NICOLE LOPEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2025
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9333 SW 152ND ST
PALMETTO BAY FL
33157-1778
US

IV. Provider business mailing address

4506 E AQUA BELLA LN
FORT LAUDERDALE FL
33312-5651
US

V. Phone/Fax

Practice location:
  • Phone: 305-251-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9119782
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: