Healthcare Provider Details

I. General information

NPI: 1508186818
Provider Name (Legal Business Name): HEATHER NICOLE LOPEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS HEATHER NICOLE MITCHELL

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 DUTCH VALLEY DR
KNOXVILLE TN
37918-1424
US

IV. Provider business mailing address

PO BOX 15004
KNOXVILLE TN
37901-5004
US

V. Phone/Fax

Practice location:
  • Phone: 865-689-1122
  • Fax: 866-340-3781
Mailing address:
  • Phone: 865-541-8895
  • Fax: 865-633-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49769
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: