Healthcare Provider Details

I. General information

NPI: 1245645134
Provider Name (Legal Business Name): RAMONA LOPEZ REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KINNICKINNIC RIVER PKWY SUITE 245
MILWAUKEE WI
53215-3669
US

IV. Provider business mailing address

4815 S 21ST STREET
MILWAUKEE WI
53221
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-6780
  • Fax:
Mailing address:
  • Phone: 414-736-4617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number146327-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: