Provider Demographics
NPI:1184353765
Name:LOPEZ, MICHELLE (COMMUNITY HEALTH WOR)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:COMMUNITY HEALTH WOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 SERVICE AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1014
Mailing Address - Country:US
Mailing Address - Phone:401-222-9157
Mailing Address - Fax:
Practice Address - Street 1:171 SERVICE AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1014
Practice Address - Country:US
Practice Address - Phone:401-222-9157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI172V00000XMedicaid