Basic Information
| Provider Information | |||||||||
| NPI: | 1992831473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5743 W MESA AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937223179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592740299 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3467 W SHAW AVE | ||||||||
| Address2: | SUITE #102 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937113223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592740299 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 171M00000X | CA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 100332 | 01 | CA | STAFF NUMBER | OTHER |