Provider Demographics
NPI:1265291074
Name:CORDOVA, MICHELLE ANGELA (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANGELA
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANGELA
Other - Last Name:BENTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3553
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-3553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 TAOS DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87305
Practice Address - Country:US
Practice Address - Phone:425-306-1689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM66892163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant