Basic Information
| Provider Information | |||||||||
| NPI: | 1477587079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 WALLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064149559 | ||||||||
| FaxNumber: | 8063513765 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S COULTER ST | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064149559 | ||||||||
| FaxNumber: | 8063513765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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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 | 207Q00000X | L2431 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 151785608 | 05 | TX | MEDICAID | 100848160A | 05 | OK | MEDICAID | 151785606 | 05 | TX | MEDICAID | 151785607 | 05 | TX | MEDICAID | 84426756 | 05 | NM | MEDICAID |