Provider Demographics
NPI:1972102192
Name:JACOMINO LOPEZ, IVONNE ILEANA (FNP)
Entity type:Individual
Prefix:
First Name:IVONNE
Middle Name:ILEANA
Last Name:JACOMINO LOPEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4661 W 8TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3517
Mailing Address - Country:US
Mailing Address - Phone:786-728-0785
Mailing Address - Fax:
Practice Address - Street 1:4661 W 8TH LN
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3517
Practice Address - Country:US
Practice Address - Phone:786-728-0785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9342058163W00000X
FL11009290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse