Provider Demographics
NPI:1659349298
Name:LOPEZ, MARY ELLEN (CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 HARKLE RD STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4753
Mailing Address - Country:US
Mailing Address - Phone:505-954-1459
Mailing Address - Fax:505-466-1729
Practice Address - Street 1:531 HARKLE RD STE B
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4753
Practice Address - Country:US
Practice Address - Phone:505-954-1459
Practice Address - Fax:505-780-8578
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR44765363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
2511165OtherUHC
QMYPR0068053OtherMOLINA
NMNM006B02OtherBCBS NM
NM92729274Medicaid
10018453OtherLOVELACE
202003563OtherPRESBYTERIAN HEALTH PLANS
QMYPR0068053OtherMOLINA