Provider Demographics
NPI:1508689779
Name:AIVAZE, MIKIA
Entity type:Individual
Prefix:
First Name:MIKIA
Middle Name:
Last Name:AIVAZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19331 PINE VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1403
Mailing Address - Country:US
Mailing Address - Phone:818-934-3463
Mailing Address - Fax:
Practice Address - Street 1:19331 PINE VALLEY AVE
Practice Address - Street 2:
Practice Address - City:PORTER RANCH
Practice Address - State:CA
Practice Address - Zip Code:91326-1403
Practice Address - Country:US
Practice Address - Phone:818-934-3463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00000000163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care