Basic Information
| Provider Information | |||||||||
| NPI: | 1568686368 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NAVAL HEALTH CLINIC HAWAII | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 480 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | PEARL HARBOR | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968604908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084731880 | ||||||||
| FaxNumber: | 8084730884 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | PEARL HARBOR | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968604908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084711866 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 07/21/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUBOIS | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE | ||||||||
| AuthorizedOfficialTelephone: | 8085901728 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R.N. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 55912 | HI | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.