Healthcare Provider Details

I. General information

NPI: 1467764712
Provider Name (Legal Business Name): MS. JAMIE LYNN ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 BALDWIN AVE
PAIA HI
96779
US

IV. Provider business mailing address

580 LAIE DR
MAKAWAO HI
96768-8902
US

V. Phone/Fax

Practice location:
  • Phone: 808-579-9134
  • Fax:
Mailing address:
  • Phone: 808-268-3268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAT 5827
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: