Provider Demographics
NPI:1720707276
Name:LOPEZ, AISHA
Entity type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 6TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-1459
Mailing Address - Country:US
Mailing Address - Phone:772-453-0595
Mailing Address - Fax:
Practice Address - Street 1:1850 6TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32962-1459
Practice Address - Country:US
Practice Address - Phone:772-453-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114976900Medicaid