Provider Demographics
NPI:1265046155
Name:LOPEZ, BRITTANY
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
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 1:1745 N BROADWAY STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-1940
Mailing Address - Country:US
Mailing Address - Phone:805-739-3890
Mailing Address - Fax:805-347-7697
Practice Address - Street 1:1745 N BROADWAY STE 101
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-1940
Practice Address - Country:US
Practice Address - Phone:805-739-3890
Practice Address - Fax:805-347-7697
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA60631363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program