Healthcare Provider Details

I. General information

NPI: 1407473846
Provider Name (Legal Business Name): VANESSA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2783 S MILLARD CV
MAGNA UT
84044-1582
US

IV. Provider business mailing address

2783 S MILLARD CV
MAGNA UT
84044-1582
US

V. Phone/Fax

Practice location:
  • Phone: 801-860-9105
  • Fax:
Mailing address:
  • Phone: 801-860-9105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number8288528-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number8288528-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: