Healthcare Provider Details

I. General information

NPI: 1275803090
Provider Name (Legal Business Name): NINA SUMMERS MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68-090 AU ST #512E
WAIALUA HI
96791-9451
US

IV. Provider business mailing address

68-090 AU ST #512E
WAIALUA HI
96791-9451
US

V. Phone/Fax

Practice location:
  • Phone: 808-224-3548
  • Fax: 808-440-5617
Mailing address:
  • Phone: 808-224-3548
  • Fax: 808-440-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT 12326
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: