Healthcare Provider Details

I. General information

NPI: 1083546980
Provider Name (Legal Business Name): MALISSA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5205 OAK PARK RD STE B
RALEIGH NC
27612-3071
US

IV. Provider business mailing address

5205 OAK PARK RD STE B
RALEIGH NC
27612-3071
US

V. Phone/Fax

Practice location:
  • Phone: 919-438-3158
  • Fax:
Mailing address:
  • Phone: 919-438-3158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13510
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: