Healthcare Provider Details

I. General information

NPI: 1518349901
Provider Name (Legal Business Name): ANDREA CORDOVA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SMITH HAVEN MALL STE 105
LAKE GROVE NY
11755-1219
US

IV. Provider business mailing address

47 FOREST AVE
LAKE GROVE NY
11755-1528
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2599
  • Fax:
Mailing address:
  • Phone: 631-379-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number623051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: