Healthcare Provider Details

I. General information

NPI: 1285451880
Provider Name (Legal Business Name): STEPHANIE L NICKERSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CENTRAL AVE
JBPHH HI
96860-4908
US

IV. Provider business mailing address

514 OHANA NUI CIR
HONOLULU HI
96818-4425
US

V. Phone/Fax

Practice location:
  • Phone: 808-473-1880
  • Fax:
Mailing address:
  • Phone: 813-380-1341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2400
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: