Provider Demographics
NPI:1639501687
Name:LOPEZ, MAYLENE (NP-C)
Entity Type:Individual
Prefix:
First Name:MAYLENE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-4281
Mailing Address - Country:US
Mailing Address - Phone:903-746-1032
Mailing Address - Fax:214-712-2444
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:SUITE 550
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-712-2074
Practice Address - Fax:214-712-2444
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX735525363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner