Provider Demographics
NPI:1659662724
Name:LOPEZ, TINYAMARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:TINYAMARIE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MISTYPOND CIRCLE
Mailing Address - Street 2:6
Mailing Address - City:MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11955-1117
Mailing Address - Country:US
Mailing Address - Phone:631-680-4245
Mailing Address - Fax:
Practice Address - Street 1:54 MISTYPOND CIRCLE
Practice Address - Street 2:6
Practice Address - City:MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11955-1117
Practice Address - Country:US
Practice Address - Phone:631-680-4245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305321-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse