Provider Demographics
NPI:1497397707
Name:LOPEZ, MELISSA CARYN (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:CARYN
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:C
Other - Last Name:LEVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 MYRTLE WAY
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-9111
Mailing Address - Country:US
Mailing Address - Phone:815-608-4673
Mailing Address - Fax:
Practice Address - Street 1:700 MYRTLE WAY
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-9111
Practice Address - Country:US
Practice Address - Phone:815-608-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041355297363LF0000X
WI1060933363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1235125717OtherGRP NPI