Provider Demographics
NPI:1033743778
Name:LOPEZ, ANGELLA
Entity Type:Individual
Prefix:
First Name:ANGELLA
Middle Name:
Last Name: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 1:420 BULLARD AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1054
Mailing Address - Country:US
Mailing Address - Phone:559-801-2626
Mailing Address - Fax:
Practice Address - Street 1:745 E LOCUST AVE STE 110
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3000
Practice Address - Country:US
Practice Address - Phone:559-801-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14378235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty