Provider Demographics
NPI:1033993514
Name:LOPEZ, MICQAUELLA RENEA
Entity type:Individual
Prefix:
First Name:MICQAUELLA
Middle Name:RENEA
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 1:9501 N TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78573-4606
Mailing Address - Country:US
Mailing Address - Phone:956-651-2555
Mailing Address - Fax:
Practice Address - Street 1:601 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-4684
Practice Address - Country:US
Practice Address - Phone:956-651-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer