Provider Demographics
NPI:1255836904
Name:HAGHNAZARIAN, SHAKEH (NP)
Entity Type:Individual
Prefix:
First Name:SHAKEH
Middle Name:
Last Name:HAGHNAZARIAN
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 1:1163 WINCHESTER AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-1828
Mailing Address - Country:US
Mailing Address - Phone:818-522-5396
Mailing Address - Fax:
Practice Address - Street 1:1163 WINCHESTER AVE APT 6
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-1828
Practice Address - Country:US
Practice Address - Phone:818-522-5396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008753363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner