Provider Demographics
NPI:1770027401
Name:DE CORDOVA, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:DE 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 1:6625 WOOLDRIDGE RD
Mailing Address - Street 2:#101
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-2916
Mailing Address - Country:US
Mailing Address - Phone:361-356-6441
Mailing Address - Fax:
Practice Address - Street 1:6625 WOOLDRIDGE RD
Practice Address - Street 2:#101
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-2916
Practice Address - Country:US
Practice Address - Phone:361-356-6441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132821363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health