Healthcare Provider Details

I. General information

NPI: 1164387262
Provider Name (Legal Business Name): OLIVIA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

IV. Provider business mailing address

212 S 42ND ST APT 2R
PHILADELPHIA PA
19104-3558
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP034678
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: