Provider Demographics
NPI:1316717333
Name:LOPEZ, CONSTANCE ELYSE (FNP-C)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:ELYSE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:ELYSE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1100 CENTRAL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4930
Mailing Address - Country:US
Mailing Address - Phone:505-841-1234
Mailing Address - Fax:
Practice Address - Street 1:1100 CENTRAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4930
Practice Address - Country:US
Practice Address - Phone:505-841-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine