Healthcare Provider Details

I. General information

NPI: 1497406813
Provider Name (Legal Business Name): IRINA MKCHYAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11645 WILSHIRE BLVD
LOS ANGELES CA
90025-1708
US

IV. Provider business mailing address

18138 COLCHESTER WAY
PORTER RANCH CA
91326-2021
US

V. Phone/Fax

Practice location:
  • Phone: 424-293-8861
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP95019138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: