Provider Demographics
NPI:1740053446
Name:BOLBOLIAN, VANE (NP)
Entity type:Individual
Prefix:MRS
First Name:VANE
Middle Name:
Last Name:BOLBOLIAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-1532
Mailing Address - Country:US
Mailing Address - Phone:818-809-6064
Mailing Address - Fax:
Practice Address - Street 1:1451 E CHEVY CHASE DR STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4056
Practice Address - Country:US
Practice Address - Phone:818-265-2245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily