Healthcare Provider Details

I. General information

NPI: 1114580826
Provider Name (Legal Business Name): MARY THERESA SELF RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 MOTT-SMITH DR APT D
HONOLULU HI
96822-2802
US

IV. Provider business mailing address

1651 MOTT-SMITH DR APT D
HONOLULU HI
96822-2802
US

V. Phone/Fax

Practice location:
  • Phone: 808-202-1534
  • Fax:
Mailing address:
  • Phone: 808-202-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number65441
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: