Basic Information
| Provider Information | |||||||||
| NPI: | 1760093553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | KARRINA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 E NORTHERN AVE UNIT 2051 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850204182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026703394 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 350 W THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2020 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 241799 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.