Provider Demographics
NPI:1134501687
Name:REYES, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:REYES
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 1:1245 KUALA ST, STE 103
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3900
Mailing Address - Country:US
Mailing Address - Phone:808-456-2273
Mailing Address - Fax:
Practice Address - Street 1:1245 KUALA ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-3900
Practice Address - Country:US
Practice Address - Phone:808-456-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1877363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health