Provider Demographics
NPI:1225534068
Name:LOPEZ, CARLA P
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:P
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 1:1399 RODNEY DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-7036
Mailing Address - Country:US
Mailing Address - Phone:860-205-3084
Mailing Address - Fax:
Practice Address - Street 1:1399 RODNEY DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-7036
Practice Address - Country:US
Practice Address - Phone:860-205-3084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0216317Medicaid