Provider Demographics
NPI:1841029543
Name:LOPEZ, CARSON NICOLE (CNA)
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:NICOLE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W RUDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62827-1130
Mailing Address - Country:US
Mailing Address - Phone:618-384-8472
Mailing Address - Fax:
Practice Address - Street 1:304 W RUDOLPH ST
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62827-1130
Practice Address - Country:US
Practice Address - Phone:618-384-8472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider