Provider Demographics
NPI:1164974127
Name:WONG, KAILIE (APRN)
Entity Type:Individual
Prefix:
First Name:KAILIE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KAILIE
Other - Middle Name:
Other - Last Name:SHIBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 S BERETANIA ST STE 601
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2423
Mailing Address - Country:US
Mailing Address - Phone:808-691-8900
Mailing Address - Fax:
Practice Address - Street 1:550 S BERETANIA ST STE 601
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2423
Practice Address - Country:US
Practice Address - Phone:808-691-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2200363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI810649Medicaid