Provider Demographics
NPI:1861855785
Name:LOPEZ, KELLY (FPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:FPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3716
Mailing Address - Country:US
Mailing Address - Phone:623-910-2777
Mailing Address - Fax:
Practice Address - Street 1:320 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3716
Practice Address - Country:US
Practice Address - Phone:505-361-1167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN1630486163W00000X
COAPN.0996117-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse