Provider Demographics
NPI:1073286498
Name:LOPEZ FONTANEZ, JESSICA M
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:LOPEZ FONTANEZ
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 1:5605 MAUNA LOA BLVD UNIT 113
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8942
Mailing Address - Country:US
Mailing Address - Phone:813-534-8196
Mailing Address - Fax:
Practice Address - Street 1:5605 MAUNA LOA BLVD UNIT 113
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240-8942
Practice Address - Country:US
Practice Address - Phone:813-534-8196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11013145363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11013145Medicaid