MEDICARE: DIVYA AMARA GILLESPIE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		CA
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1407488711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVYA AMARA GILLESPIE

Provider Business Mailing Address
First Line	:	8945 GOLF LINKS RD
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94605-4124
Country	:	US
Telephone Number	:	510-654-4004
Fax Number	:

Provider Business Practice Location Address
First Line	:	2300 PANAMA ST
Second Line	:
City	:	HAYWARD
State	:	CA
Zip	:	94545-4662
Country	:	US
Telephone Number	:	510-414-3436
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2020
Last Update Date	:	09/23/2025

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