Healthcare Provider Details

I. General information

NPI: 1790400604
Provider Name (Legal Business Name): KRISTINE GEVORGYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N BRAND BLVD STE 230
GLENDALE CA
91203-4443
US

IV. Provider business mailing address

401 N BRAND BLVD STE 230
GLENDALE CA
91203-4443
US

V. Phone/Fax

Practice location:
  • Phone: 747-203-0016
  • Fax: 747-300-0061
Mailing address:
  • Phone: 747-203-0016
  • Fax: 747-300-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95194439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: