Healthcare Provider Details

I. General information

NPI: 1376470526
Provider Name (Legal Business Name): PADMAJA NANDULA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 S OVERLOOK DR
SAN RAMON CA
94582-4544
US

IV. Provider business mailing address

A. 1075 CREEKSIDE RIDGE SUITE 280 ROSEVILLE
ROSEVILLE CA
95678
US

V. Phone/Fax

Practice location:
  • Phone: 925-309-9064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: