Basic Information
| Provider Information | |||||||||
| NPI: | 1053401653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | RUTH | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 PHOENIX AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067021418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037568021 | ||||||||
| FaxNumber: | 2035969038 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 SEYMOUR STREET | ||||||||
| Address2: | HARTFORD HOSPITAL ADULT PRIMARY CARE | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605450200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 002807 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 001028072 | 05 | CT | MEDICAID |