Healthcare Provider Details

I. General information

NPI: 1306618590
Provider Name (Legal Business Name): NIKKITA DINNELLA PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1846 E INTREPID AVE
MESA AZ
85204-6817
US

IV. Provider business mailing address

2241 12TH ST SW
BACKUS MN
56435-2273
US

V. Phone/Fax

Practice location:
  • Phone: 480-992-4221
  • Fax: 480-992-7445
Mailing address:
  • Phone: 480-992-4221
  • Fax: 480-992-7445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number248193
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: