Healthcare Provider Details

I. General information

NPI: 1043802317
Provider Name (Legal Business Name): KRISTIA LEANNE FUENTES APRN-RX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTIA LEANNE DIZON APRN-RX

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S BERETANIA ST
HONOLULU HI
96814-1870
US

IV. Provider business mailing address

94-745 MEHEULA PKWY APT 18C
MILILANI HI
96789-4021
US

V. Phone/Fax

Practice location:
  • Phone: 808-206-5301
  • Fax:
Mailing address:
  • Phone: 206-372-1484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-3124
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: