Provider Demographics
NPI:1740376656
Name:LOPEZ, KELLIE TOSHIYE (FNP)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:TOSHIYE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:KELLIE
Other - Middle Name:TOSHIYE
Other - Last Name:KELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2103 MONTROSE AVENUE SUITE D
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020
Mailing Address - Country:US
Mailing Address - Phone:818-319-3911
Mailing Address - Fax:
Practice Address - Street 1:2103 MONTROSE AVENUE SUITE D
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020
Practice Address - Country:US
Practice Address - Phone:818-319-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP15929363LF0000X
CA557311363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA557311OtherRNP
CABK082ZMedicare PIN