Provider Demographics
NPI:1760095525
Name:LOPEZ BLANCO, DISELIA (FNP)
Entity Type:Individual
Prefix:
First Name:DISELIA
Middle Name:
Last Name:LOPEZ BLANCO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22905 SW 131ST AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-2775
Mailing Address - Country:US
Mailing Address - Phone:786-942-2618
Mailing Address - Fax:786-536-5689
Practice Address - Street 1:1695 NW 110TH AVE STE 218
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-1929
Practice Address - Country:US
Practice Address - Phone:305-456-7580
Practice Address - Fax:786-536-5689
Is Sole Proprietor?:No
Enumeration Date:2020-08-30
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF08200411363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily