Provider Demographics
NPI:1548813595
Name:CORDON, JUANA MARINA
Entity type:Individual
Prefix:
First Name:JUANA
Middle Name:MARINA
Last Name:CORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CLIFFORD AVE APT 65
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-2142
Mailing Address - Country:US
Mailing Address - Phone:702-773-1349
Mailing Address - Fax:
Practice Address - Street 1:2300 CLIFFORD AVE APT 65
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-2142
Practice Address - Country:US
Practice Address - Phone:702-773-1349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV21057736563747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2105773656OtherIDENTIFICATION CARD