Healthcare Provider Details

I. General information

NPI: 1235831652
Provider Name (Legal Business Name): DIANA KIRAKOSYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 N VERMONT AVE
LOS ANGELES CA
90029-1704
US

IV. Provider business mailing address

9900 CABANAS AVE
TUJUNGA CA
91042-2929
US

V. Phone/Fax

Practice location:
  • Phone: 323-660-5624
  • Fax:
Mailing address:
  • Phone: 818-319-6483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number742425
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number742425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: