Provider Demographics
NPI:1659646511
Name:CORDERO, DEZIRAE R (CNA,)
Entity Type:Individual
Prefix:
First Name:DEZIRAE
Middle Name:R
Last Name:CORDERO
Suffix:
Gender:F
Credentials:CNA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 W CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-1017
Mailing Address - Country:US
Mailing Address - Phone:623-640-4300
Mailing Address - Fax:
Practice Address - Street 1:7500 N DREAMY DRAW DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4660
Practice Address - Country:US
Practice Address - Phone:602-325-1606
Practice Address - Fax:602-906-8216
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCNA1000016799390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program