Healthcare Provider Details

I. General information

NPI: 1023600814
Provider Name (Legal Business Name): MARISSA LYN CHEAPE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 22ND AVE RM 127
HONOLULU HI
96816-4400
US

IV. Provider business mailing address

475 22ND AVE RM 127
HONOLULU HI
96816-4400
US

V. Phone/Fax

Practice location:
  • Phone: 808-627-7300
  • Fax:
Mailing address:
  • Phone: 808-348-0538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP1604
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: