Provider Demographics
NPI:1285347948
Name:CORDOVA, AVERY CORRINE
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:CORRINE
Last Name:CORDOVA
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 1:354 S HALCYON RD STE C
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3879
Mailing Address - Country:US
Mailing Address - Phone:805-473-7060
Mailing Address - Fax:
Practice Address - Street 1:354 S HALCYON RD STE C
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3879
Practice Address - Country:US
Practice Address - Phone:805-473-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37349167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician