Healthcare Provider Details

I. General information

NPI: 1477890820
Provider Name (Legal Business Name): NICOLE B. QUEYREL MAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2013
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 S KING ST SUITE #205
HONOLULU HI
96826-3508
US

IV. Provider business mailing address

1501 SAINT LOUIS DR
HONOLULU HI
96816-1920
US

V. Phone/Fax

Practice location:
  • Phone: 808-942-1144
  • Fax:
Mailing address:
  • Phone: 808-224-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberMAT 7653
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: