1093141731 NPI number — MRS. KELLY MARIE CORDERO NP, CNS

Table of content: MRS. KELLY MARIE CORDERO NP, CNS (NPI 1093141731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093141731 NPI number — MRS. KELLY MARIE CORDERO NP, CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORDERO
Provider First Name:
KELLY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP, CNS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093141731
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
695 MONTEREY BLVD APT 302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94127-2363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-330-5612
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 PASTEUR DRIVE, HC029
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STANFORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94305-5222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-701-5936
Provider Business Practice Location Address Fax Number:
650-721-5079
Provider Enumeration Date:
09/25/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  22532 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364S00000X , with the licence number: 3686 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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