Healthcare Provider Details

I. General information

NPI: 1013943455
Provider Name (Legal Business Name): NICOLE LOUISE HODGEBOOM NP MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S BERETANIA ST STE 950
HONOLULU HI
96814-1874
US

IV. Provider business mailing address

1401 S BERETANIA ST STE 950
HONOLULU HI
96814-1874
US

V. Phone/Fax

Practice location:
  • Phone: 808-983-6675
  • Fax: 808-373-7577
Mailing address:
  • Phone: 808-983-6675
  • Fax: 808-373-7577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN-2521
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: