Provider Demographics
NPI:1225675358
Name:LOPEZ, NICOLE (MS,LAT,ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MS,LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 USTA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7329
Mailing Address - Country:US
Mailing Address - Phone:407-675-2798
Mailing Address - Fax:
Practice Address - Street 1:10000 USTA BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827
Practice Address - Country:US
Practice Address - Phone:407-675-2798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL-6213207X00000X
NCLAT-4037207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty