Provider Demographics
NPI:1528818986
Name:LOPEZ, DEJA M (RN)
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-5112
Mailing Address - Country:US
Mailing Address - Phone:801-577-4661
Mailing Address - Fax:
Practice Address - Street 1:252 W BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84101-3024
Practice Address - Country:US
Practice Address - Phone:801-363-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13398422-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse