Healthcare Provider Details

I. General information

NPI: 1134590508
Provider Name (Legal Business Name): AMANDA M L WONG APRN, AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S BERETANIA ST STE 601
HONOLULU HI
96813-2423
US

IV. Provider business mailing address

2017 IHOLENA ST APT B
HONOLULU HI
96817-2160
US

V. Phone/Fax

Practice location:
  • Phone: 808-691-7775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN-1924
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: