Provider Demographics
NPI:1699737411
Name:LOPEZ AGUEDA, IVETTE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:IVETTE
Middle Name:
Last Name:LOPEZ AGUEDA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4027 ADAIR LN
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-9464
Mailing Address - Country:US
Mailing Address - Phone:336-538-4965
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD # DUMC3094
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4699
Practice Address - Country:US
Practice Address - Phone:919-668-0289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC79915367500000X
NC207539367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052596Medicaid
NC8052596Medicaid