Provider Demographics
NPI:1134487226
Name:CORDOVA, KISMET KRYSTEL VINE
Entity Type:Individual
Prefix:
First Name:KISMET KRYSTEL
Middle Name:VINE
Last Name:CORDOVA
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 1:605 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1400
Mailing Address - Country:US
Mailing Address - Phone:213-236-9388
Mailing Address - Fax:213-489-7993
Practice Address - Street 1:605 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1400
Practice Address - Country:US
Practice Address - Phone:213-236-9388
Practice Address - Fax:213-489-7993
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA258247164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse