Healthcare Provider Details

I. General information

NPI: 1760160865
Provider Name (Legal Business Name): OLU WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16-590 OLD VOLCANO RD STE B
KEAAU HI
96749-8158
US

IV. Provider business mailing address

16-590 OLD VOLCANO RD STE B
KEAAU HI
96749-8158
US

V. Phone/Fax

Practice location:
  • Phone: 808-430-0794
  • Fax: 808-930-4721
Mailing address:
  • Phone: 808-430-0794
  • Fax: 808-930-4721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RAE LYNNE NEWPHER
Title or Position: OWNER
Credential: APRN
Phone: 808-430-0794