Healthcare Provider Details

I. General information

NPI: 1174197099
Provider Name (Legal Business Name): STACEY ANNE WILLIAMS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2021
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 S BERETANIA ST
HONOLULU HI
96814-1520
US

IV. Provider business mailing address

94-1169 KUKULA ST
WAIPAHU HI
96797-5261
US

V. Phone/Fax

Practice location:
  • Phone: 808-210-4444
  • Fax:
Mailing address:
  • Phone: 801-368-8508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-1406
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: