Provider Demographics
NPI:1649924648
Name:LOPEZ, MIRANDA NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NICOLE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W WALNUT AVE APT 60
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2249
Mailing Address - Country:US
Mailing Address - Phone:714-400-5628
Mailing Address - Fax:
Practice Address - Street 1:2854 N SANTIAGO BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-1700
Practice Address - Country:US
Practice Address - Phone:714-771-7047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301679225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist