Basic Information
| Provider Information | |||||||||
| NPI: | 1598110611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | VANESSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1625 DIAMOND HILL RD | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028951771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017621511 | ||||||||
| FaxNumber: | 4017621609 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 DIAMOND HILL RD | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028951771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017621511 | ||||||||
| FaxNumber: | 4017621609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2016 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 54802 | RI | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 050444312 | 05 | RI | MEDICAID |