Provider Demographics
NPI:1477302305
Name:GRIGORYAN, TATEVIK
Entity type:Individual
Prefix:
First Name:TATEVIK
Middle Name:
Last Name:GRIGORYAN
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 1:18325 SHERMAN WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335
Mailing Address - Country:US
Mailing Address - Phone:818-414-1981
Mailing Address - Fax:
Practice Address - Street 1:39159 PASEO PADRE PKWY STE 121
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1600
Practice Address - Country:US
Practice Address - Phone:510-952-1190
Practice Address - Fax:510-972-5976
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95222787163W00000X
CA95028093363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse