Provider Demographics
NPI:1033680574
Name:FONTANEZ LOPEZ, YAHAIRA IVETTE
Entity Type:Individual
Prefix:
First Name:YAHAIRA
Middle Name:IVETTE
Last Name:FONTANEZ LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SILVER PARK CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-9400
Mailing Address - Country:US
Mailing Address - Phone:407-924-6076
Mailing Address - Fax:
Practice Address - Street 1:22 SILVER PARK CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-9400
Practice Address - Country:US
Practice Address - Phone:407-924-6076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty