Provider Demographics
NPI:1104451921
Name:KUPALYAN, MARINE
Entity type:Individual
Prefix:
First Name:MARINE
Middle Name:
Last Name:KUPALYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10833 LE CONTE 22-387 MDCC
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1752
Mailing Address - Country:US
Mailing Address - Phone:310-825-5930
Mailing Address - Fax:310-794-7338
Practice Address - Street 1:10833 LE CONTE 22-387 MDCC
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1752
Practice Address - Country:US
Practice Address - Phone:310-825-5930
Practice Address - Fax:310-794-7338
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95145365163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty