Healthcare Provider Details

I. General information

NPI: 1801205521
Provider Name (Legal Business Name): IRACENA S LOPES AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WARREN AVE STE 302
EAST PROVIDENCE RI
02914-1430
US

IV. Provider business mailing address

10 DAVOL SQ STE 400
PROVIDENCE RI
02903-4760
US

V. Phone/Fax

Practice location:
  • Phone: 800-508-4908
  • Fax: 401-490-5505
Mailing address:
  • Phone: 401-421-4000
  • Fax: 401-272-1456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN01010
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: