Provider Demographics
NPI:1255903498
Name:LOPEZ, JENNA (FNP-C)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 EMILY CROSSING CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-5689
Mailing Address - Country:US
Mailing Address - Phone:702-755-6610
Mailing Address - Fax:
Practice Address - Street 1:98 E LAKE MEAD PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-5540
Practice Address - Country:US
Practice Address - Phone:702-483-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCNP844875363LF0000X
NVF07210863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2500015208Medicaid