Provider Demographics
NPI:1649450941
Name:CORDOVA, CAROLYN MARY (RD,MPH,CDE)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:MARY
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:RD,MPH,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:400 W 16TH ST
Mailing Address - Street 2:PARKVIEW MEDICAL CENTER
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2745
Mailing Address - Country:US
Mailing Address - Phone:719-584-4358
Mailing Address - Fax:719-583-7304
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:PARKVIEW MEDICAL CENTER
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-584-4358
Practice Address - Fax:719-583-7304
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO718076133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO481788Medicare PIN