Healthcare Provider Details

I. General information

NPI: 1265965321
Provider Name (Legal Business Name): PHYLAVANH PHANHTHARATH ACNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 WAIANUENUE AVE
HILO HI
96720-2094
US

IV. Provider business mailing address

1190 WAIANUENUE AVE
HILO HI
96720-2094
US

V. Phone/Fax

Practice location:
  • Phone: 808-932-3000
  • Fax:
Mailing address:
  • Phone: 808-932-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberAPRN-2756
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License NumberAP133384
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: