Provider Demographics
NPI:1831198597
Name:KABAIVANOFF, DEBRA L (ARNP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:KABAIVANOFF
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 W SARAH ST
Mailing Address - Street 2:#26
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505
Mailing Address - Country:US
Mailing Address - Phone:818-561-4062
Mailing Address - Fax:
Practice Address - Street 1:4420 W SARAH ST
Practice Address - Street 2:#26
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-561-4062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3304052363LA2200X
CA19585363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACZ028XMedicare PIN
FLAB219ZMedicare PIN
FLQ76054Medicare UPIN
CACZ028YMedicare PIN