Provider Demographics
NPI:1013400035
Name:GAVURMADZHYAN, NAIRA
Entity Type:Individual
Prefix:
First Name:NAIRA
Middle Name:
Last Name:GAVURMADZHYAN
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 1:1316 TRUITT ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-2341
Mailing Address - Country:US
Mailing Address - Phone:818-321-6601
Mailing Address - Fax:
Practice Address - Street 1:1316 TRUITT ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2341
Practice Address - Country:US
Practice Address - Phone:818-321-6601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA971929133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty