Healthcare Provider Details

I. General information

NPI: 1225637234
Provider Name (Legal Business Name): LUPO PREVENTATIVE MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10020 NICHOLAS STREET SUITE 106
OMAHA NE
68114-2188
US

IV. Provider business mailing address

10020 NICHOLAS STREET SUITE 106
OMAHA NE
68114-2188
US

V. Phone/Fax

Practice location:
  • Phone: 402-226-5211
  • Fax:
Mailing address:
  • Phone: 402-226-5211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MOLLY R LUPO
Title or Position: OWNER
Credential: APRN
Phone: 402-226-5211