Healthcare Provider Details

I. General information

NPI: 1730739806
Provider Name (Legal Business Name): ALEXIS KISHIMOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 12/11/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98-820 MOANALUA RD SPC 5
AIEA HI
96701-5200
US

IV. Provider business mailing address

98-820 MOANALUA RD SPC 5
AIEA HI
96701-5200
US

V. Phone/Fax

Practice location:
  • Phone: 808-721-6476
  • Fax:
Mailing address:
  • Phone: 808-721-6476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: