Provider Demographics
NPI:1174197099
Name:WILLIAMS, STACEY ANNE (FNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANNE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-1169 KUKULA ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-5261
Mailing Address - Country:US
Mailing Address - Phone:801-368-8508
Mailing Address - Fax:
Practice Address - Street 1:1360 S BERETANIA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1520
Practice Address - Country:US
Practice Address - Phone:808-210-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-15
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
HIAPRN-1406363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program