Healthcare Provider Details

I. General information

NPI: 1912287244
Provider Name (Legal Business Name): NELLIESHY MAMUAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 HINANO ST
HILO HI
96720-4427
US

IV. Provider business mailing address

622 HINANO ST
HILO HI
96720-4427
US

V. Phone/Fax

Practice location:
  • Phone: 808-589-1829
  • Fax: 808-589-2610
Mailing address:
  • Phone: 808-589-1829
  • Fax: 808-589-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: