Provider Demographics
NPI:1073260063
Name:FUENTES, KIARA NICOLE
Entity Type:Individual
Prefix:
First Name:KIARA
Middle Name:NICOLE
Last Name:FUENTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2098 ALA MAHAMOE ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1627
Mailing Address - Country:US
Mailing Address - Phone:808-388-2067
Mailing Address - Fax:
Practice Address - Street 1:203 KAPPA QUARRY PL
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-247-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-19-79203106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician