Provider Demographics
NPI:1720305667
Name:LOPEZ, SANDRA JANE (CHA IV)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JANE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:CHA IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3380 C STREET,
Mailing Address - Street 2:STE. 100
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-3949
Mailing Address - Country:US
Mailing Address - Phone:907-277-1440
Mailing Address - Fax:907-277-1446
Practice Address - Street 1:65 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:COLD BAY
Practice Address - State:AK
Practice Address - Zip Code:99571
Practice Address - Country:US
Practice Address - Phone:907-532-2000
Practice Address - Fax:907-532-2001
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK08-964-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL6515Medicaid