Provider Demographics
NPI:1295317923
Name:LOPEZ, GABRIELA
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
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 1:623 S ALDER ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-2201
Mailing Address - Country:US
Mailing Address - Phone:360-630-9840
Mailing Address - Fax:
Practice Address - Street 1:623 S ALDER ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-2201
Practice Address - Country:US
Practice Address - Phone:360-630-9840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171R00000X
WAMC55875171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171R00000XOther Service ProvidersInterpreterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMC55875Medicaid