Provider Demographics
NPI:1447272661
Name:LOPEZ, JANNETTE (APRN)
Entity type:Individual
Prefix:
First Name:JANNETTE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 HOSKINS RD
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-1306
Mailing Address - Country:US
Mailing Address - Phone:203-887-5762
Mailing Address - Fax:860-352-2006
Practice Address - Street 1:323 CROMWELL AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067
Practice Address - Country:US
Practice Address - Phone:860-563-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002787363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004228202Medicaid
CT400002787CT01OtherBCBS
CT004228202Medicaid
CT500029977Medicare ID - Type Unspecified