Healthcare Provider Details

I. General information

NPI: 1235696741
Provider Name (Legal Business Name): DIVYA REBECCA ROBERTS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MERCHANT ST STE 2900
HONOLULU HI
96813-4384
US

IV. Provider business mailing address

2191 LAUKAHI ST
HONOLULU HI
96821-2619
US

V. Phone/Fax

Practice location:
  • Phone: 808-536-8012
  • Fax: 808-536-8013
Mailing address:
  • Phone: 716-200-9457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN-3612
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: