Provider Demographics
NPI:1356004576
Name:CORDOVA, ANGIE MADELINE
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:MADELINE
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 1:5354 SEDONA CREEK CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-1711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:148 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5372
Practice Address - Country:US
Practice Address - Phone:321-972-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician