MEDICARE: MRS. KIMI A PRENTICE APRN

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	363L00000X	Nurse Practitioner	1147	HI

General Provider Information

NPI Number	:	1467684480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMI A PRENTICE APRN

Provider Business Mailing Address
First Line	:	91-2139 FORT WEAVER RD STE 100
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-3608
Country	:	US
Telephone Number	:	808-676-4224
Fax Number	:	808-676-4220

Provider Business Practice Location Address
First Line	:	91-2139 FORT WEAVER RD STE 108
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-3608
Country	:	US
Telephone Number	:	808-676-4224
Fax Number	:

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

Provider Enumeration Date	:	08/10/2009
Last Update Date	:	11/11/2021

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