Provider Demographics
NPI:1093582546
Name:GRIGORYAN, SIRANUSH
Entity type:Individual
Prefix:
First Name:SIRANUSH
Middle Name:
Last Name:GRIGORYAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12812 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-4315
Mailing Address - Country:US
Mailing Address - Phone:747-888-2584
Mailing Address - Fax:
Practice Address - Street 1:13630 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-3600
Practice Address - Country:US
Practice Address - Phone:747-888-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2025-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034155363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty