Provider Demographics
NPI:1710733258
Name:CORDOVA, EVANGELINE DATU (APRN)
Entity type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:DATU
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16235 SW 103RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-4903
Mailing Address - Country:US
Mailing Address - Phone:305-492-2022
Mailing Address - Fax:
Practice Address - Street 1:16235 SW 103RD TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-4903
Practice Address - Country:US
Practice Address - Phone:305-492-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11031148363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty