1801246467 NPI number — MRS. JACQULYN NICOLE LOPEZ MSN, RN, FNP-C

Table of content: MRS. JACQULYN NICOLE LOPEZ MSN, RN, FNP-C (NPI 1801246467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801246467 NPI number — MRS. JACQULYN NICOLE LOPEZ MSN, RN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
JACQULYN
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURGESS
Provider Other First Name:
JACQULYN
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801246467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8935 N. MERIDIAN STREET
Provider Second Line Business Mailing Address:
SUITE #107
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-924-2390
Provider Business Mailing Address Fax Number:
317-924-2391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8935 N. MERIDIAN STREET
Provider Second Line Business Practice Location Address:
SUITE #107
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-924-2390
Provider Business Practice Location Address Fax Number:
317-924-2391
Provider Enumeration Date:
06/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  28190531A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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