Provider Demographics
NPI:1497320006
Name:CORDOVA, IVONNE (LND)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 256
Mailing Address - Street 2:
Mailing Address - City:BAJADERO
Mailing Address - State:PR
Mailing Address - Zip Code:00616-0256
Mailing Address - Country:US
Mailing Address - Phone:787-406-0443
Mailing Address - Fax:
Practice Address - Street 1:657 STREET, KM 1, ARENALEJOS
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00616-0256
Practice Address - Country:US
Practice Address - Phone:787-406-0443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1346133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist