Provider Demographics
NPI:1952111551
Name:CORDOVA, KRISTA JAYLENE
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:JAYLENE
Last Name: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 1:1730 S VICTORIA AVE.
Mailing Address - Street 2:STE. B, STUDIO # 12
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003
Mailing Address - Country:US
Mailing Address - Phone:951-440-7651
Mailing Address - Fax:
Practice Address - Street 1:1730 S VICTORIA AVE.
Practice Address - Street 2:STE. B, STUDIO # 12
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:951-440-7651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84188225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist