Provider Demographics
NPI:1962735605
Name:LOPEZ, MILDRED RODRIGUEZ (BSN, RN, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:RODRIGUEZ
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:BSN, RN, IBCLC
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Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:USA MEDDAC ATTN: CREDENTIALS, FORT DRUM, NY
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-4025
Mailing Address - Fax:315-772-9498
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:USA MEDDAC/CREDENTIALS
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:315-772-4025
Practice Address - Fax:315-772-9498
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY478635-1163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health