Healthcare Provider Details

I. General information

NPI: 1831003300
Provider Name (Legal Business Name): CARRIE ANN LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 S 12TH ST
BISMARCK ND
58504-6640
US

IV. Provider business mailing address

1513 S 12TH ST
BISMARCK ND
58504-6640
US

V. Phone/Fax

Practice location:
  • Phone: 701-595-3779
  • Fax: 701-425-0446
Mailing address:
  • Phone: 701-595-3779
  • Fax: 701-425-0446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: