Provider Demographics
NPI:1114580826
Name:SELF, MARY THERESA (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESA
Last Name:SELF
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 MOTT-SMITH DR APT D
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-2802
Mailing Address - Country:US
Mailing Address - Phone:808-202-1534
Mailing Address - Fax:
Practice Address - Street 1:1651 MOTT-SMITH DR APT D
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822-2802
Practice Address - Country:US
Practice Address - Phone:808-202-1534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI65441163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics