Provider Demographics
NPI:1922424985
Name:LOPEZ, ISIS KARENSHA
Entity Type:Individual
Prefix:
First Name:ISIS
Middle Name:KARENSHA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 NE BARAGAR AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470
Mailing Address - Country:US
Mailing Address - Phone:541-236-5997
Mailing Address - Fax:541-236-5291
Practice Address - Street 1:1223 NE BARAGAR AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-5621
Practice Address - Country:US
Practice Address - Phone:541-236-5997
Practice Address - Fax:541-236-5291
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17016174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist