Healthcare Provider Details

I. General information

NPI: 1336215938
Provider Name (Legal Business Name): CARRIE LYNN LOPEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE LYNN WLODARCHAK

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 GEMINI CIR STE 2
OTTAWA IL
61350-1695
US

IV. Provider business mailing address

725 SCHOOL ST STE A
MORRIS IL
60450-1207
US

V. Phone/Fax

Practice location:
  • Phone: 815-433-0850
  • Fax:
Mailing address:
  • Phone: 815-705-1405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-000855
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: