Healthcare Provider Details

I. General information

NPI: 1790622751
Provider Name (Legal Business Name): JELISSA FERNANDA HERNANDEZ LOPEZ DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 27TH ST
LUMBERTON NC
28358-3075
US

IV. Provider business mailing address

3729 PAULINE LN
CHARLOTTE NC
28216-8902
US

V. Phone/Fax

Practice location:
  • Phone: 980-216-0545
  • Fax:
Mailing address:
  • Phone: 980-216-0545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: