Provider Demographics
NPI:1184031213
Name:CORDOVA, KEMBERLY JISSELL
Entity Type:Individual
Prefix:
First Name:KEMBERLY
Middle Name:JISSELL
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 1:1555 E FLAMINGO RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5258
Mailing Address - Country:US
Mailing Address - Phone:702-385-9097
Mailing Address - Fax:
Practice Address - Street 1:1555 E FLAMINGO RD STE 158
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-9305
Practice Address - Country:US
Practice Address - Phone:702-385-9097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner