Provider Demographics
NPI:1154171106
Name:AVAGIMIAN, GAYANE (PMHNP)
Entity type:Individual
Prefix:
First Name:GAYANE
Middle Name:
Last Name:AVAGIMIAN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 E SAN JOSE AVE UNIT 104
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-3606
Mailing Address - Country:US
Mailing Address - Phone:213-219-5063
Mailing Address - Fax:
Practice Address - Street 1:12215 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3206
Practice Address - Country:US
Practice Address - Phone:213-219-5063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028855363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health