Provider Demographics
NPI:1871533760
Name:SHAGRAMANOVA, KRISTINA
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:SHAGRAMANOVA
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 1:7924 WOODMAN AVE
Mailing Address - Street 2:SUITE27
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91402-6246
Mailing Address - Country:US
Mailing Address - Phone:818-636-9208
Mailing Address - Fax:
Practice Address - Street 1:410 W COLORADO ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1504
Practice Address - Country:US
Practice Address - Phone:818-956-9907
Practice Address - Fax:818-956-9914
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA551301223G0001X
PADS0371311223G0001X
246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic