Healthcare Provider Details

I. General information

NPI: 1326535105
Provider Name (Legal Business Name): NINIA R CARVAJAL N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W LEXINGTON DR STE 303B
GLENDALE CA
91203-2203
US

IV. Provider business mailing address

121 W LEXINGTON DR STE 303B
GLENDALE CA
91203-2203
US

V. Phone/Fax

Practice location:
  • Phone: 818-671-0012
  • Fax: 818-671-5581
Mailing address:
  • Phone: 626-274-5411
  • Fax: 818-671-5581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95006625
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95006625
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: