Provider Demographics
NPI:1871077214
Name:LOPEZ, CRYSTAL LYNN (LVN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LYNN
Other - Last Name:LIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:250 N SEE VEE LANE
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-8130
Mailing Address - Country:US
Mailing Address - Phone:760-873-8461
Mailing Address - Fax:760-873-3935
Practice Address - Street 1:250 N SEE VEE LANE
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-8130
Practice Address - Country:US
Practice Address - Phone:760-873-8461
Practice Address - Fax:760-873-3935
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA209814164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP11576FMedicaid