Healthcare Provider Details

I. General information

NPI: 1366266355
Provider Name (Legal Business Name): ALYSSA NICOLE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 WAIAKAMILO RD STE 202
HONOLULU HI
96817-4950
US

IV. Provider business mailing address

420 WAIAKAMILO RD STE 202
HONOLULU HI
96817-4950
US

V. Phone/Fax

Practice location:
  • Phone: 808-845-0102
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-392645
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: