Healthcare Provider Details

I. General information

NPI: 1497449508
Provider Name (Legal Business Name): AMBAR KRYSTAL LOPEZ AGOSTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 AVENIDA CESAR E CHAVEZ
KANSAS CITY MO
64108-2133
US

IV. Provider business mailing address

519 AVENIDA CESAR E CHAVEZ
KANSAS CITY MO
64108-2133
US

V. Phone/Fax

Practice location:
  • Phone: 818-913-1910
  • Fax:
Mailing address:
  • Phone: 888-913-1910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA24138
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30005226
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: