Healthcare Provider Details

I. General information

NPI: 1124788963
Provider Name (Legal Business Name): KAYCEE MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 ALA MOANA BLVD STE 1
HONOLULU HI
96814-4262
US

IV. Provider business mailing address

2402 PUUNOA PL
HONOLULU HI
96816-3419
US

V. Phone/Fax

Practice location:
  • Phone: 808-585-1424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: