Healthcare Provider Details

I. General information

NPI: 1639721319
Provider Name (Legal Business Name): GENESIS NICOLE AYALA LOPEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB LAS LOMAS S-3 #1 CARR 21
SAN JUAN PR
00921
US

IV. Provider business mailing address

PO BOX 405
SAN LORENZO PR
00754-0405
US

V. Phone/Fax

Practice location:
  • Phone: 939-716-3884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35141
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number3014767
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number022419
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number22419
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: