Provider Demographics
NPI:1871010793
Name:MATA LOPEZ, LAURA REBECA (NP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:REBECA
Last Name:MATA LOPEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 EL CERRITO PLZ UNIT 315
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-4012
Mailing Address - Country:US
Mailing Address - Phone:718-416-5113
Mailing Address - Fax:
Practice Address - Street 1:2023 VALE RD
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3834
Practice Address - Country:US
Practice Address - Phone:510-215-9092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007152363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health