Healthcare Provider Details

I. General information

NPI: 1821119702
Provider Name (Legal Business Name): TEDDY CORDERO BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

1456 COOL SPRING WAY
VIRGINIA BEACH VA
23464-8880
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-3521
  • Fax:
Mailing address:
  • Phone: 757-321-0538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number1168742
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: