Healthcare Provider Details

I. General information

NPI: 1073260063
Provider Name (Legal Business Name): KIARA NICOLE FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 03/09/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KAPPA QUARRY PL
KAILUA HI
96734
US

IV. Provider business mailing address

2098 ALA MAHAMOE ST
HONOLULU HI
96819-1627
US

V. Phone/Fax

Practice location:
  • Phone: 808-247-2973
  • Fax:
Mailing address:
  • Phone: 808-388-2067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-79203
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: