Healthcare Provider Details

I. General information

NPI: 1104750702
Provider Name (Legal Business Name): LUSINE MKHITARYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 E BROADWAY
GLENDALE CA
91205-1110
US

IV. Provider business mailing address

519 E BROADWAY
GLENDALE CA
91205-1110
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-2030
  • Fax:
Mailing address:
  • Phone: 818-409-2030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95039750
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: