Provider Demographics
NPI:1104651306
Name:MKRTUMYAN, ALVINA (NP)
Entity type:Individual
Prefix:
First Name:ALVINA
Middle Name:
Last Name:MKRTUMYAN
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 1:13140 BASSETT ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-4726
Mailing Address - Country:US
Mailing Address - Phone:818-399-6823
Mailing Address - Fax:
Practice Address - Street 1:18040 SHERMAN WAY STE 204
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4656
Practice Address - Country:US
Practice Address - Phone:818-964-2222
Practice Address - Fax:747-267-7878
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027021261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care