Provider Demographics
NPI:1104576909
Name:LOPEZ, ANDREA NICOLE (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:NICOLE
Last Name:LOPEZ
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10935 TERRA VISTA PKWY APT 103
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6350
Mailing Address - Country:US
Mailing Address - Phone:909-377-9291
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST BLDG SUITEC
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1716
Practice Address - Country:US
Practice Address - Phone:909-558-9532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A221202084P0804X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry