Provider Demographics
NPI:1043321383
Name:LOPEZ, KATHRYN A
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
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 1:16 GALLBERRY CT
Mailing Address - Street 2:
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-6058
Mailing Address - Country:US
Mailing Address - Phone:386-931-5755
Mailing Address - Fax:
Practice Address - Street 1:16 GALLBERRY CT
Practice Address - Street 2:
Practice Address - City:BUNNELL
Practice Address - State:FL
Practice Address - Zip Code:32110-6058
Practice Address - Country:US
Practice Address - Phone:386-931-5755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL68927196174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist