Healthcare Provider Details

I. General information

NPI: 1184623605
Provider Name (Legal Business Name): MARY LUCILLE CAMERON CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 OKA ST
KILAUEA HI
96754-5308
US

IV. Provider business mailing address

2460 OKA ST
KILAUEA HI
96754-5308
US

V. Phone/Fax

Practice location:
  • Phone: 808-828-2885
  • Fax: 928-367-1330
Mailing address:
  • Phone: 808-828-2885
  • Fax: 928-367-1330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN032228
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN1040
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: