Provider Demographics
NPI:1396184255
Name:LOPEZ, MARY BETH (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:APRN
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Mailing Address - Street 1:10755 N US HIGHWAY 25E
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:KY
Mailing Address - Zip Code:40734-6529
Mailing Address - Country:US
Mailing Address - Phone:606-258-8050
Mailing Address - Fax:606-258-8994
Practice Address - Street 1:39 CUMBERLAND GAP PLZ
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:KY
Practice Address - Zip Code:40734-4536
Practice Address - Country:US
Practice Address - Phone:606-526-9005
Practice Address - Fax:606-526-8607
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2019-01-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY3008095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100348960Medicaid