Healthcare Provider Details

I. General information

NPI: 1760716153
Provider Name (Legal Business Name): MS. STEPHANIE ANTIONETTE JOY LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 WOODLAWN DR.
GWYNN OAK MD
21207-4043
US

IV. Provider business mailing address

11 N EUTAW ST APT. 624
BALTIMORE MD
21201-1765
US

V. Phone/Fax

Practice location:
  • Phone: 410-887-1332
  • Fax: 410-887-1386
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR185356
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: