Healthcare Provider Details

I. General information

NPI: 1457100299
Provider Name (Legal Business Name): ALYSHA DELPHINE ENBOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSHA DELPHINE HARTSHORN

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 06/26/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 624
HANAPEPE HI
96716-0624
US

IV. Provider business mailing address

PO BOX 624
HANAPEPE HI
96716-0624
US

V. Phone/Fax

Practice location:
  • Phone: 360-301-5568
  • Fax:
Mailing address:
  • Phone: 360-301-5568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number55667
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61092439
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number103027
License Number StateHI
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-4642
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: