MEDICARE: KELLY P LOPEZ NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209.020409	IL
2	363L00000X	Nurse Practitioner	209020409	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	209.020409	OTHER	IL	IL LICENSE

General Provider Information

NPI Number	:	1679118301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY P LOPEZ NP-C

Provider Business Mailing Address
First Line	:	725 SCHOOL ST STE A
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-1207
Country	:	US
Telephone Number	:	815-941-9124
Fax Number	:	815-941-4363

Provider Business Practice Location Address
First Line	:	105 SARAVANOS RD
Second Line	:
City	:	YORKVILLE
State	:	IL
Zip	:	60560-5813
Country	:	US
Telephone Number	:	630-553-4600
Fax Number	:	630-553-7486

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2019
Last Update Date	:	07/29/2021

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Directions to “ KELLY P LOPEZ NP-C” Practice Location

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