Healthcare Provider Details

I. General information

NPI: 1700765641
Provider Name (Legal Business Name): MRS. CHAZLEY MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 08/27/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KAPAA QUARRY PL #5002
KAILUA HI
96734
US

IV. Provider business mailing address

45-458 NAKULUAI ST
KANEOHE HI
96744-2221
US

V. Phone/Fax

Practice location:
  • Phone: 808-247-2973
  • Fax:
Mailing address:
  • Phone: 808-373-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1403258
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: