Healthcare Provider Details

I. General information

NPI: 1639620222
Provider Name (Legal Business Name): MIND BODY NUTRITION RN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-5995 KUAKINI HWY STE 445
KAILUA KONA HI
96740-2123
US

IV. Provider business mailing address

75-5995 KUAKINI HWY STE 445
KAILUA KONA HI
96740-2123
US

V. Phone/Fax

Practice location:
  • Phone: 808-315-8466
  • Fax:
Mailing address:
  • Phone: 808-315-8466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number2154
License Number StateHI

VIII. Authorized Official

Name: DEBORAH VANCE-BEAUMONT
Title or Position: OWNER
Credential: APRN
Phone: 415-867-6457