Provider Demographics
NPI:1114298569
Name:DESA-SHISHIDO, JACQUELINE C (LPN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:C
Last Name:DESA-SHISHIDO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 PUNCHBOWL ST
Mailing Address - Street 2:RM 256
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2416
Mailing Address - Country:US
Mailing Address - Phone:808-590-7320
Mailing Address - Fax:808-586-4675
Practice Address - Street 1:15-2866 PAHOA VILLAGE RD
Practice Address - Street 2:BLDG E.
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-7720
Practice Address - Country:US
Practice Address - Phone:808-965-2241
Practice Address - Fax:808-965-2240
Is Sole Proprietor?:No
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI9065164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse