Healthcare Provider Details

I. General information

NPI: 1912309949
Provider Name (Legal Business Name): GAMAL LOPEZ APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 LAKE ALFRED RD
WINTER HAVEN FL
33881-1432
US

IV. Provider business mailing address

81 LAKE RING DR
WINTER HAVEN FL
33884-1422
US

V. Phone/Fax

Practice location:
  • Phone: 863-291-4590
  • Fax: 863-508-6503
Mailing address:
  • Phone: 305-799-8607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11046343
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: