Provider Demographics
NPI:1255049433
Name:BLANCO LOPEZ, FERNANDA MARCELINA
Entity type:Individual
Prefix:
First Name:FERNANDA
Middle Name:MARCELINA
Last Name:BLANCO 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 1:10201 RIVERDALE RD LOT 176
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-2917
Mailing Address - Country:US
Mailing Address - Phone:720-723-8365
Mailing Address - Fax:
Practice Address - Street 1:2490 W 26TH AVE STE 10A
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-5300
Practice Address - Country:US
Practice Address - Phone:303-331-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0024128225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist