Healthcare Provider Details

I. General information

NPI: 1225756901
Provider Name (Legal Business Name): NICOLLETTE BALASSANIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 1ST ST
SAN FERNANDO CA
91340-2957
US

IV. Provider business mailing address

3824 4TH AVE
GLENDALE CA
91214-2317
US

V. Phone/Fax

Practice location:
  • Phone: 818-256-1124
  • Fax:
Mailing address:
  • Phone: 818-399-8507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: