Healthcare Provider Details

I. General information

NPI: 1174120489
Provider Name (Legal Business Name): SHEEBA KALAPPURAKKAL DIVAKARAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 N 6TH AVE APT A8
PHOENIX AZ
85013-3738
US

IV. Provider business mailing address

3601 N 6TH AVE APT A8
PHOENIX AZ
85013-3738
US

V. Phone/Fax

Practice location:
  • Phone: 602-653-3075
  • Fax:
Mailing address:
  • Phone: 602-653-3075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number255711
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number141069
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: