MEDICARE: KELLI ANN IFUKU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1366905184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI ANN IFUKU

Provider Business Mailing Address
First Line	:	1557 ALA MAHAMOE ST
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96819-1766
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5400 S RAINBOW BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-1825
Country	:	US
Telephone Number	:	702-853-3561
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2019
Last Update Date	:	04/09/2019

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Directions to “ KELLI ANN IFUKU ” Practice Location

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