Healthcare Provider Details

I. General information

NPI: 1871010793
Provider Name (Legal Business Name): LAURA REBECA MATA LOPEZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 HOSPITAL DR STE 106
GLEN BURNIE MD
21061-5806
US

IV. Provider business mailing address

325 HOSPITAL DR STE 106
GLEN BURNIE MD
21061-5806
US

V. Phone/Fax

Practice location:
  • Phone: 443-430-2998
  • Fax:
Mailing address:
  • Phone: 443-430-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR251462
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95007152
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: