Healthcare Provider Details

I. General information

NPI: 1023470986
Provider Name (Legal Business Name): KAREN DONNA STUART FALLIS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1637 G STREET
KAILUA HI
96734
US

IV. Provider business mailing address

1602 MALABEY ST
KAILUA HI
96734-5029
US

V. Phone/Fax

Practice location:
  • Phone: 850-590-1301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-477
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL5567
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-3045
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01007
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: