Healthcare Provider Details

I. General information

NPI: 1205994183
Provider Name (Legal Business Name): COLLETTE MICHELLE WILSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96-1100 KAMANI STREET
PAHALA HI
96777-0067
US

IV. Provider business mailing address

PO BOX 67
PAHALA HI
96777-0067
US

V. Phone/Fax

Practice location:
  • Phone: 808-987-7490
  • Fax:
Mailing address:
  • Phone: 808-987-7490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00021673
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAT-12043
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: