Healthcare Provider Details

I. General information

NPI: 1598038788
Provider Name (Legal Business Name): WAYNETTE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2012
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 CALLE DE LA MERCED
ESPANOLA NM
87532-2624
US

IV. Provider business mailing address

PO BOX 28220
SANTA FE NM
87592-8220
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-0081
  • Fax:
Mailing address:
  • Phone: 505-471-5006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-07833
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: