Healthcare Provider Details

I. General information

NPI: 1588939599
Provider Name (Legal Business Name): CONNICE WANG RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 06/08/2024
Certification Date: 06/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 SPENCER ST APT N
HONOLULU HI
96822-5119
US

IV. Provider business mailing address

1060 SPENCER ST APT N
HONOLULU HI
96822-5119
US

V. Phone/Fax

Practice location:
  • Phone: 808-620-3863
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1090602
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: