Provider Demographics
NPI:1063106797
Name:TAVATYAN, LILIT (NP)
Entity type:Individual
Prefix:
First Name:LILIT
Middle Name:
Last Name:TAVATYAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 E COLORADO ST STE C
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-4555
Mailing Address - Country:US
Mailing Address - Phone:818-243-8133
Mailing Address - Fax:818-243-8413
Practice Address - Street 1:702 E COLORADO ST STE C
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4555
Practice Address - Country:US
Practice Address - Phone:818-243-8133
Practice Address - Fax:818-243-8413
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025336363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner