Provider Demographics
NPI:1295202372
Name:COLON-LOPEZ, EDNA
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:COLON-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 1:2717 EAGLE CANYON DR S
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-3170
Mailing Address - Country:US
Mailing Address - Phone:407-914-9168
Mailing Address - Fax:
Practice Address - Street 1:1060 CYPRESS PKWY STE 104
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-3328
Practice Address - Country:US
Practice Address - Phone:407-914-9168
Practice Address - Fax:407-337-8005
Is Sole Proprietor?:No
Enumeration Date:2018-10-27
Last Update Date:2023-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA76628225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist