Healthcare Provider Details

I. General information

NPI: 1821658378
Provider Name (Legal Business Name): CAITLIN LOPEZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

2211 FORT ST
WYANDOTTE MI
48192-4135
US

IV. Provider business mailing address

28150 ROSE AVE
BROWNSTOWN TWP MI
48183-4833
US

V. Phone/Fax

Practice location:
  • Phone: 734-357-0505
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704301757
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: