Provider Demographics
NPI:1184644668
Name:MAMACLAY, BLANDINA C (APRN)
Entity Type:Individual
Prefix:
First Name:BLANDINA
Middle Name:C
Last Name:MAMACLAY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 N KING ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4544
Mailing Address - Country:US
Mailing Address - Phone:808-848-1438
Mailing Address - Fax:808-843-7270
Practice Address - Street 1:915 N KING ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-4544
Practice Address - Country:US
Practice Address - Phone:808-848-1438
Practice Address - Fax:808-843-7270
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-119363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0051863101Medicaid
HI0051863101Medicaid
H52285Medicare ID - Type Unspecified