Healthcare Provider Details

I. General information

NPI: 1851750194
Provider Name (Legal Business Name): KATHLEEN MELLON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2-2514 KAUMUALII HWY #21
KALAHEO HI
96741-8303
US

IV. Provider business mailing address

2-2514 KAUMUALII HWY #21
KALAHEO HI
96741-8303
US

V. Phone/Fax

Practice location:
  • Phone: 808-332-5580
  • Fax: 808-332-5583
Mailing address:
  • Phone: 808-332-5580
  • Fax: 808-332-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberACU-314
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: