Provider Demographics
NPI:1780304063
Name:LOPEZ, MARY T
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17801 INDUSTRIAL FARM RD
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-9599
Mailing Address - Country:US
Mailing Address - Phone:661-861-1020
Mailing Address - Fax:
Practice Address - Street 1:17801 INDUSTRIAL FARM RD
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-9599
Practice Address - Country:US
Practice Address - Phone:661-861-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN58742164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse