Healthcare Provider Details

I. General information

NPI: 1851034110
Provider Name (Legal Business Name): NICOLE MARIE LOPEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST
KEESLER AFB MS
39534-2508
US

IV. Provider business mailing address

3165 SW 133RD PL
MIAMI FL
33175-6653
US

V. Phone/Fax

Practice location:
  • Phone: 228-376-2273
  • Fax:
Mailing address:
  • Phone: 786-269-8043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35.151039
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: