Healthcare Provider Details

I. General information

NPI: 1043063084
Provider Name (Legal Business Name): ISLANDMED CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7192 KALANIANAOLE HWY STE G210
HONOLULU HI
96825-1849
US

IV. Provider business mailing address

7192 KALANIANAOLE HWY STE G210
HONOLULU HI
96825-1849
US

V. Phone/Fax

Practice location:
  • Phone: 808-431-0870
  • Fax: 808-431-0880
Mailing address:
  • Phone: 808-431-0870
  • Fax: 808-431-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NATALIA WEST
Title or Position: OWNER/PROVIDER
Credential: FNP-BC
Phone: 808-431-0870