Healthcare Provider Details

I. General information

NPI: 1497671044
Provider Name (Legal Business Name): MARISA LOPEZ CORDOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2026
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 TRAWOOD DR STE 100
EL PASO TX
79936-4122
US

IV. Provider business mailing address

4922 CHASE CT
SAINT CLOUD FL
34772-8966
US

V. Phone/Fax

Practice location:
  • Phone: 719-310-9996
  • Fax:
Mailing address:
  • Phone: 719-310-9996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11046979
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1246459
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: