Basic Information
| Provider Information | |||||||||
| NPI: | 1902895071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ-AGOSTO | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | LOPEZ | ||||||||
| OtherFirstName: | DIANA | ||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11750 E COLONIAL DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328174656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038235055 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11750 E COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328174624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8446654827 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 003135 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | ARNP9365957 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.