Provider Demographics
NPI:1457694432
Name:LOPEZ, IVONNE (NP)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E RYAN RD
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-4563
Mailing Address - Country:US
Mailing Address - Phone:414-570-3590
Mailing Address - Fax:
Practice Address - Street 1:200 E RYAN RD
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-4563
Practice Address - Country:US
Practice Address - Phone:414-570-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5258363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner