Provider Demographics
NPI:1629638333
Name:CORDOVA, KAITLIN OLIVIA (PT DPT)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:OLIVIA
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 CORBIN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-1895
Mailing Address - Country:US
Mailing Address - Phone:606-526-2909
Mailing Address - Fax:606-526-2901
Practice Address - Street 1:1138 S HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-3523
Practice Address - Country:US
Practice Address - Phone:606-677-2006
Practice Address - Fax:606-677-1779
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist