Provider Demographics
NPI:1083204085
Name:FLORES, ANDREA JO (MT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JO
Last Name:FLORES
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 283
Mailing Address - Street 2:
Mailing Address - City:KUNIA
Mailing Address - State:HI
Mailing Address - Zip Code:96759-0220
Mailing Address - Country:US
Mailing Address - Phone:719-588-4495
Mailing Address - Fax:
Practice Address - Street 1:98-1005 MOANALUA RD SPC 235
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4707
Practice Address - Country:US
Practice Address - Phone:808-488-8588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15636225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist