Healthcare Provider Details

I. General information

NPI: 1871189266
Provider Name (Legal Business Name): GAYANE MKRTCHYAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1509 WILSON TER
GLENDALE CA
91206-4007
US

IV. Provider business mailing address

1018 VIRGINIA PL UNIT 2
GLENDALE CA
91204-2266
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-8000
  • Fax:
Mailing address:
  • Phone: 818-731-4633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95015795
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95015795
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: