Healthcare Provider Details

I. General information

NPI: 1598982100
Provider Name (Legal Business Name): IRINA KAPULKIN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17777 VENTURA BLVD STE 200
ENCINO CA
91316-3748
US

IV. Provider business mailing address

17777 VENTURA BLVD STE 200
ENCINO CA
91316-3748
US

V. Phone/Fax

Practice location:
  • Phone: 818-990-6400
  • Fax:
Mailing address:
  • Phone: 818-990-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number44540
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95016281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: