MEDICARE: CHARISSA ANYEL LOPEZ PMHNP

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	163WP0808X	Psychiatric/Mental Health Registered Nurse	AP7463	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750788584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARISSA ANYEL LOPEZ PMHNP

Provider Business Mailing Address
First Line	:	1255 W BASELINE RD STE 138
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-5821
Country	:	US
Telephone Number	:	480-820-5422
Fax Number	:	480-775-4938

Provider Business Practice Location Address
First Line	:	1255 W BASELINE RD STE 138
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-5821
Country	:	US
Telephone Number	:	480-820-5422
Fax Number	:	480-775-4938

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

Provider Enumeration Date	:	11/21/2014
Last Update Date	:	11/21/2014

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