Healthcare Provider Details

I. General information

NPI: 1689258691
Provider Name (Legal Business Name): MADISON JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 KALANIANAOLE HWY SPC 5001
KAILUA HI
96734-4669
US

IV. Provider business mailing address

5144 CALAPINI LN
KAILUA HI
96734-4995
US

V. Phone/Fax

Practice location:
  • Phone: 808-247-2973
  • Fax:
Mailing address:
  • Phone: 512-698-2696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: