Healthcare Provider Details

I. General information

NPI: 1902731698
Provider Name (Legal Business Name): KRYSTINE ANN WAGGONER CABRERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MCCULLY ST APT 402
HONOLULU HI
96826-3939
US

IV. Provider business mailing address

620 MCCULLY ST APT 402
HONOLULU HI
96826-3939
US

V. Phone/Fax

Practice location:
  • Phone: 425-230-7317
  • Fax:
Mailing address:
  • Phone: 425-230-7317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW-3425-0
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: