Healthcare Provider Details

I. General information

NPI: 1073376612
Provider Name (Legal Business Name): ELIZABETH MARATOVNA KHAVKINA PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14860 ROSCOE BLVD STE 307
PANORAMA CITY CA
91402-4691
US

IV. Provider business mailing address

11901 LOUISE AVE
GRANADA HILLS CA
91344-2449
US

V. Phone/Fax

Practice location:
  • Phone: 818-616-2122
  • Fax:
Mailing address:
  • Phone: 323-717-9626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95037175
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95311194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: