Healthcare Provider Details

I. General information

NPI: 1538064621
Provider Name (Legal Business Name): MARY MARGARET FILLMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 HONU LOOP
AIEA HI
96701-4238
US

IV. Provider business mailing address

1185 HONU LOOP
AIEA HI
96701-4238
US

V. Phone/Fax

Practice location:
  • Phone: 865-742-0076
  • Fax:
Mailing address:
  • Phone: 865-742-0076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-6230
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: