Healthcare Provider Details

I. General information

NPI: 1184554586
Provider Name (Legal Business Name): CHLORISSA NICOLE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 DAKOTA ST SE
ALBUQUERQUE NM
87108-4921
US

IV. Provider business mailing address

2501 YALE BLVD SE
ALBUQUERQUE NM
87106-4200
US

V. Phone/Fax

Practice location:
  • Phone: 210-984-4620
  • Fax:
Mailing address:
  • Phone: 210-984-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: