Provider Demographics
NPI:1750103362
Name:LOPEZ, JENNIFER LYNN (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:811 STATE ROAD 206 E STE 3
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4869
Practice Address - Country:US
Practice Address - Phone:904-342-2989
Practice Address - Fax:904-824-6243
Is Sole Proprietor?:No
Enumeration Date:2024-10-26
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAPRN11035987363L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine