Provider Demographics
NPI:1184358996
Name:CORDOVA, DOMINIQUE Y (PTA)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:Y
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 SW 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2513
Mailing Address - Country:US
Mailing Address - Phone:305-450-4475
Mailing Address - Fax:
Practice Address - Street 1:435 NW RUTLAND RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-8700
Practice Address - Country:US
Practice Address - Phone:615-773-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28180225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty