Healthcare Provider Details

I. General information

NPI: 1154509578
Provider Name (Legal Business Name): SHANON LEE SIDELL N.D., LAC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68-1845 WAIKOLOA RD SUITE #201
WAIKOLOA HI
96738-5584
US

IV. Provider business mailing address

PO BOX 383194
WAIKOLOA HI
96738-3194
US

V. Phone/Fax

Practice location:
  • Phone: 808-960-8333
  • Fax: 877-992-6761
Mailing address:
  • Phone: 808-960-8333
  • Fax: 877-992-6761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number989
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMAT-4731
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number171
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: