Healthcare Provider Details

I. General information

NPI: 1073797023
Provider Name (Legal Business Name): KELLI CORDOVA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5281 NW WICKIUP WAY
PORTLAND OR
97229-7160
US

IV. Provider business mailing address

5281 NW WICKIUP WAY
PORTLAND OR
97229-7160
US

V. Phone/Fax

Practice location:
  • Phone: 503-430-0625
  • Fax:
Mailing address:
  • Phone: 503-430-0625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: