Basic Information
| Provider Information | |||||||||
| NPI: | 1174559157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOUTROUBA | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RANDLE | ||||||||
| OtherFirstName: | DENISE | ||||||||
| OtherMiddleName: | MICHELE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NURSE PRACTITIONER | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | JARRETT WHITE ROAD | ||||||||
| Address2: | TRIPLER ARMY MEDICAL CENTER ATTN: MCHK-QS | ||||||||
| City: | TRIPLER AMC | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968595001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084332460 | ||||||||
| FaxNumber: | 8084331558 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 JARRETT WHITE RD | ||||||||
| Address2: | TRIPLER ARMY MEDICAL CENTER ATTN: MCHK-QS | ||||||||
| City: | TRIPLER AMC | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968595001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084332460 | ||||||||
| FaxNumber: | 8084331558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR1000X | 275890 | CA | X | Nursing Service Providers | Registered Nurse | Reproductive Endocrinology/Infertility | 363LW0102X | 275890 | CA | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LW0102X | 264283 | MA | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 275890 | 01 | CA | LICENSE | OTHER | 37 | 01 | HI | NURSE PRACTITIONER | OTHER | 264283 | 01 | MA | NURSE PRACTITIONER LICENS | OTHER |