Provider Demographics
NPI:1386218022
Name:FAKHIRIYAZDI, MASTANEH MAY (FNP)
Entity Type:Individual
Prefix:
First Name:MASTANEH
Middle Name:MAY
Last Name:FAKHIRIYAZDI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 N SAN VICENTE BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3890
Mailing Address - Country:US
Mailing Address - Phone:703-835-4595
Mailing Address - Fax:
Practice Address - Street 1:912 N SAN VICENTE BLVD APT 3
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-3890
Practice Address - Country:US
Practice Address - Phone:703-835-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017188207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine