=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922424985
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISIS KARENSHA LOPEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2014
-----------------------------------------------------
Last Update Date | 03/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1223 NE BARAGAR AVE
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97471-5621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-236-5997
-----------------------------------------------------
Fax | 541-236-5291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1223 NE BARAGAR AVE
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-236-5997
-----------------------------------------------------
Fax | 541-236-5291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 17016
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------