Provider Demographics
NPI:1801246467
Name:LOPEZ, JACQULYN NICOLE (MSN, RN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JACQULYN
Middle Name:NICOLE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MSN, RN, FNP-C
Other - Prefix:
Other - First Name:JACQULYN
Other - Middle Name:NICOLE
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8935 N. MERIDIAN STREET
Mailing Address - Street 2:SUITE #107
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:317-924-2390
Mailing Address - Fax:317-924-2391
Practice Address - Street 1:8935 N. MERIDIAN STREET
Practice Address - Street 2:SUITE #107
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-924-2390
Practice Address - Fax:317-924-2391
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28190531A163W00000X
IN71006463A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001044600OtherANTHEM PROVIDER NUMBER
IN201384020Medicaid
INP01757146Medicare PIN
IN815500174Medicare PIN