Provider Demographics
NPI:1518367986
Name:LOPEZ, EVANGELINA MARISELA
Entity Type:Individual
Prefix:
First Name:EVANGELINA
Middle Name:MARISELA
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 1:3037 10TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-3861
Mailing Address - Country:US
Mailing Address - Phone:209-480-4862
Mailing Address - Fax:
Practice Address - Street 1:3037 10TH ST APT 4
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-3861
Practice Address - Country:US
Practice Address - Phone:209-480-4862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator