Provider Demographics
NPI:1033993514
Name:LOPEZ, MICQAUELLA
Entity Type:Individual
Prefix:
First Name:MICQAUELLA
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 1:1951 AQUARENA SPRINGS DR APT 11207
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-8236
Mailing Address - Country:US
Mailing Address - Phone:956-651-2555
Mailing Address - Fax:
Practice Address - Street 1:601 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-4684
Practice Address - Country:US
Practice Address - Phone:956-651-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program