Provider Demographics
NPI:1235774332
Name:DERHEIM, ALYSSA MARIE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:DERHEIM
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 1:1240 ALA KAPUNA ST APT 309
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-4612
Mailing Address - Country:US
Mailing Address - Phone:831-524-6381
Mailing Address - Fax:
Practice Address - Street 1:1240 ALA KAPUNA ST APT 309
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-4612
Practice Address - Country:US
Practice Address - Phone:831-524-6381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI19707164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse