Healthcare Provider Details

I. General information

NPI: 1194405787
Provider Name (Legal Business Name): AILEEN AMBARTSUMYAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 E BROADWAY
GLENDALE CA
91205-1110
US

IV. Provider business mailing address

1401 VALLEY VIEW RD APT 109
GLENDALE CA
91202-4408
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-3020
  • Fax:
Mailing address:
  • Phone: 818-275-7755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95169219
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95027985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: