Healthcare Provider Details

I. General information

NPI: 1154990612
Provider Name (Legal Business Name): MARIZZA MEJIA CORDOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2021
Last Update Date: 06/20/2021
Certification Date: 06/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S 2ND AVE
YAKIMA WA
98902-3464
US

IV. Provider business mailing address

PO BOX 959
YAKIMA WA
98907-0959
US

V. Phone/Fax

Practice location:
  • Phone: 509-575-4084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN60929094
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: