Provider Demographics
NPI:1063019842
Name:MARTINEZ DE LOPEZ, MARICELA
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:
Last Name:MARTINEZ DE 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 1:3819 MOLER ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-6041
Mailing Address - Country:US
Mailing Address - Phone:469-387-8498
Mailing Address - Fax:
Practice Address - Street 1:3819 MOLER ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-6041
Practice Address - Country:US
Practice Address - Phone:469-387-8498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider