Provider Demographics
NPI:1174120489
Name:DIVAKARAN, SHEEBA KALAPPURAKKAL (NP)
Entity type:Individual
Prefix:
First Name:SHEEBA
Middle Name:KALAPPURAKKAL
Last Name:DIVAKARAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 N 6TH AVE APT A8
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3738
Mailing Address - Country:US
Mailing Address - Phone:602-653-3075
Mailing Address - Fax:
Practice Address - Street 1:3601 N 6TH AVE APT A8
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3738
Practice Address - Country:US
Practice Address - Phone:602-653-3075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ141069163W00000X
AZ255711363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse