Provider Demographics
NPI:1760164719
Name:LOPEZ, JACQUELINE (RD/LDN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:RD/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 LOCH NESS DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-6009
Mailing Address - Country:US
Mailing Address - Phone:305-725-4331
Mailing Address - Fax:
Practice Address - Street 1:7303 LOCH NESS DR
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-6009
Practice Address - Country:US
Practice Address - Phone:305-725-4331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND9041133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered