MEDICARE: MARISA LOPEZ CORDOVA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	11046979	FL

General Provider Information

NPI Number	:	1497671044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA LOPEZ CORDOVA

Provider Business Mailing Address
First Line	:	4922 CHASE CT
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34772-8966
Country	:	US
Telephone Number	:	719-310-9996
Fax Number	:

Provider Business Practice Location Address
First Line	:	1140 S SEMORAN BLVD STE C
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32807-1459
Country	:	US
Telephone Number	:	407-965-5077
Fax Number	:	813-354-4470

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2026
Last Update Date	:	06/27/2026

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