Provider Demographics
NPI:1710535596
Name:GABRIELYAN, LOLITA
Entity Type:Individual
Prefix:
First Name:LOLITA
Middle Name:
Last Name:GABRIELYAN
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 1:620 N LOUISE ST APT 204
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-2297
Mailing Address - Country:US
Mailing Address - Phone:818-424-7667
Mailing Address - Fax:
Practice Address - Street 1:620 N LOUISE ST APT 204
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-2297
Practice Address - Country:US
Practice Address - Phone:818-424-7667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program