Provider Demographics
NPI:1861092462
Name:CORDOVA, PAIGE MARIE (LPN)
Entity type:Individual
Prefix:MISS
First Name:PAIGE
Middle Name:MARIE
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:PAIGE
Other - Middle Name:MARIE
Other - Last Name:CORDOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:608 E FRESNO AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2819
Mailing Address - Country:US
Mailing Address - Phone:580-716-8421
Mailing Address - Fax:
Practice Address - Street 1:13 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-4808
Practice Address - Country:US
Practice Address - Phone:580-761-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0067313164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse