Provider Demographics
NPI:1194020834
Name:LOPEZ-RODRIGUEZ, WANDA IVETTE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:IVETTE
Last Name:LOPEZ-RODRIGUEZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 MOUNT OLIVE RD
Mailing Address - Street 2:
Mailing Address - City:FLANDERS
Mailing Address - State:NJ
Mailing Address - Zip Code:07836-9725
Mailing Address - Country:US
Mailing Address - Phone:973-527-4722
Mailing Address - Fax:
Practice Address - Street 1:1105 ROUTE 46
Practice Address - Street 2:
Practice Address - City:LEDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07852
Practice Address - Country:US
Practice Address - Phone:973-927-4662
Practice Address - Fax:973-927-4668
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00325900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF0910124OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION NUMBER