Provider Demographics
NPI:1184761496
Name:CORDOVA, KELLY KAY (LMT)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:KAY
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:KAY
Other - Last Name:CORDOVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:2121 N BAYSHORE DR
Mailing Address - Street 2:SUITE 1106
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-5123
Mailing Address - Country:US
Mailing Address - Phone:786-290-7979
Mailing Address - Fax:
Practice Address - Street 1:2121 N BAYSHORE DR
Practice Address - Street 2:SUITE 1106
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-5123
Practice Address - Country:US
Practice Address - Phone:786-290-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 42178171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor