Healthcare Provider Details

I. General information

NPI: 1194990069
Provider Name (Legal Business Name): MARY LYNN TESHIMA M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77-5620 PALANI ROAD SUITE 102
KAILUA-KONA HI
96740
US

IV. Provider business mailing address

77-5620 PALANI ROAD SUITE 102
KAILUA-KONA HI
96740
US

V. Phone/Fax

Practice location:
  • Phone: 808-329-7797
  • Fax: 808-329-2748
Mailing address:
  • Phone: 808-329-7797
  • Fax: 808-329-2748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number10541
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: