Healthcare Provider Details

I. General information

NPI: 1124684436
Provider Name (Legal Business Name): MRS. SERENA MARIE WALTERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 KAPA'A QUARRY PL
KAILUA HI
96734
US

IV. Provider business mailing address

1782B LITTLER CT
KAILUA HI
96734-5112
US

V. Phone/Fax

Practice location:
  • Phone: 808-741-2232
  • Fax:
Mailing address:
  • Phone: 218-252-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberG597068562621
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: