=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194491456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TATIANA JENINE PEREZ BORJA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2021
-----------------------------------------------------
Last Update Date | 07/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 KEHALANI MAUKA PKWY
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793-3559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-727-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 VEVAU ST APT 308
-----------------------------------------------------
City | KAHULUI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96732-1663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-385-3730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------