Provider Demographics
NPI:1851792584
Name:LOPEZ, KELLY LAUREL (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LAUREL
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3739 RIDGE POINTE LOOP NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-7208
Mailing Address - Country:US
Mailing Address - Phone:773-899-1586
Mailing Address - Fax:
Practice Address - Street 1:6709 ACADEMY RD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3363
Practice Address - Country:US
Practice Address - Phone:505-308-3145
Practice Address - Fax:505-308-3147
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM54261163W00000X, 367500000X
IL041374254163W00000X, 163W00000X
IL209012263367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse