Healthcare Provider Details

I. General information

NPI: 1851679310
Provider Name (Legal Business Name): NIKKI JANE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NIKKI DREWES

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 06/21/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 FRONT ST # 406
PERRYVILLE MD
21903-2752
US

IV. Provider business mailing address

PO BOX 637
PERRYVILLE MD
21903-0637
US

V. Phone/Fax

Practice location:
  • Phone: 719-299-6193
  • Fax:
Mailing address:
  • Phone: 719-299-6193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number10859
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: