=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235866773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIVYA NALLI PMHNP-BC, FNP-C, MSN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2022
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1349 MAIN ST
-----------------------------------------------------
City | NEWMAN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95360-1326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-862-3604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 BLUE RANGE WAY
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95747-4497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-776-3584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95022030
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95022030
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------