Provider Demographics
NPI:1750504106
Name:LOPEZ, SUSAN LYNN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
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 1:2734 RITA DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-2257
Mailing Address - Country:US
Mailing Address - Phone:440-282-1103
Mailing Address - Fax:
Practice Address - Street 1:2734 RITA DR
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-2257
Practice Address - Country:US
Practice Address - Phone:440-282-1103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2263812Medicaid