Healthcare Provider Details

I. General information

NPI: 1699385872
Provider Name (Legal Business Name): TAZIALYNN LEILANI LYNAM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAZIALYNN LEILANI HEGARTY

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 KILAUEA AVE
HILO HI
96720-4234
US

IV. Provider business mailing address

740 KILAUEA AVE
HILO HI
96720-4234
US

V. Phone/Fax

Practice location:
  • Phone: 808-333-3420
  • Fax:
Mailing address:
  • Phone: 808-333-3420
  • Fax: 808-333-3421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-3022
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number84575
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: