Provider Demographics
NPI:1558038588
Name:LOPEZ, YESSICA FAVIOLA
Entity Type:Individual
Prefix:
First Name:YESSICA
Middle Name:FAVIOLA
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 1:46745 MONROE ST APT 146
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5555
Mailing Address - Country:US
Mailing Address - Phone:760-818-6012
Mailing Address - Fax:
Practice Address - Street 1:49869 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-9720
Practice Address - Country:US
Practice Address - Phone:760-398-9090
Practice Address - Fax:760-391-5338
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist