Healthcare Provider Details

I. General information

NPI: 1396184255
Provider Name (Legal Business Name): MARY BETH LOPEZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 CUMBERLAND GAP PLZ
GRAY KY
40734-4536
US

IV. Provider business mailing address

10755 N US HIGHWAY 25E
GRAY KY
40734-6529
US

V. Phone/Fax

Practice location:
  • Phone: 606-526-9005
  • Fax: 606-526-8607
Mailing address:
  • Phone: 606-258-8050
  • Fax: 606-258-8994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3008095
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: