Healthcare Provider Details

I. General information

NPI: 1245066620
Provider Name (Legal Business Name): DAVID MAMIK MIKAELIAN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10131 FERNGLEN AVE
TUJUNGA CA
91042-2215
US

IV. Provider business mailing address

10131 FERNGLEN AVE
TUJUNGA CA
91042-2215
US

V. Phone/Fax

Practice location:
  • Phone: 818-669-3848
  • Fax:
Mailing address:
  • Phone: 818-669-3848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06241527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: