Provider Demographics
NPI:1114178688
Name:JUSTUSSON, DIANE MELOCHE (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MELOCHE
Last Name:JUSTUSSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87-1048 HUAMOA ST
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-3435
Mailing Address - Country:US
Mailing Address - Phone:808-375-7317
Mailing Address - Fax:
Practice Address - Street 1:87-1048 HUAMOA ST
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3435
Practice Address - Country:US
Practice Address - Phone:808-375-7317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1433367A00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR279353Medicaid
WA9658972Medicaid