Basic Information
| Provider Information | |||||||||
| NPI: | 1235360801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAIN | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHMITZ | ||||||||
| OtherFirstName: | JODY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 91-1175 KUANOO ST | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967064634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082201942 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 91-2301 OLD FT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967063602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086772525 | ||||||||
| FaxNumber: | 8086772570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2009 | ||||||||
| LastUpdateDate: | 07/30/2009 | ||||||||
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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 | 163WP0808X | 39439 | HI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.