Provider Demographics
NPI:1609572619
Name:GRETCHENUK, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GRETCHENUK
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 1:2646 N BEACHWOOD DR APT 205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-2360
Mailing Address - Country:US
Mailing Address - Phone:323-919-5923
Mailing Address - Fax:
Practice Address - Street 1:15305 RAYEN ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5117
Practice Address - Country:US
Practice Address - Phone:818-892-3423
Practice Address - Fax:818-893-4509
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL