Healthcare Provider Details

I. General information

NPI: 1023051646
Provider Name (Legal Business Name): NATALYA SHAGRAMANOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 N VERDUGO RD SUITE 112
GLENDALE CA
91208-2862
US

IV. Provider business mailing address

1545 N VERDUGO RD SUITE 112
GLENDALE CA
91208-2862
US

V. Phone/Fax

Practice location:
  • Phone: 818-662-5104
  • Fax: 818-662-5063
Mailing address:
  • Phone: 818-662-5104
  • Fax: 818-662-5063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54204
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: