Provider Demographics
NPI:1700358132
Name:LOPEZ, IVY
Entity Type:Individual
Prefix:
First Name:IVY
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:W3831 DAHLIA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 E GENEVA ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-1922
Practice Address - Country:US
Practice Address - Phone:262-728-6319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-24
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI125083-30163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice