Healthcare Provider Details

I. General information

NPI: 1851792584
Provider Name (Legal Business Name): KELLY LAUREL LOPEZ CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6709 ACADEMY RD NE STE A
ALBUQUERQUE NM
87109-3363
US

IV. Provider business mailing address

3739 RIDGE POINTE LOOP NE
ALBUQUERQUE NM
87111-7208
US

V. Phone/Fax

Practice location:
  • Phone: 505-308-3145
  • Fax: 505-308-3147
Mailing address:
  • Phone: 773-899-1586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number54261
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041374254
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209012263
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number54261
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: