Provider Demographics
NPI:1790326460
Name:GANDARA LOPEZ, LINA L (MSN, APRN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:LINA
Middle Name:L
Last Name:GANDARA LOPEZ
Suffix:
Gender:F
Credentials:MSN, APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SANDOLLAR CV
Mailing Address - Street 2:
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925-3151
Mailing Address - Country:US
Mailing Address - Phone:940-882-5178
Mailing Address - Fax:
Practice Address - Street 1:611 SANDOLLAR CV
Practice Address - Street 2:
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3151
Practice Address - Country:US
Practice Address - Phone:940-882-5178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004347363L00000X
FLAPRN11004347363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner