Provider Demographics
NPI:1295399103
Name:TAGATA, ALYSSA MARIE
Entity Type:Individual
Prefix:
First Name:ALYSSA MARIE
Middle Name:
Last Name:TAGATA
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 1:91-213 KAIELEELE PL
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-4617
Mailing Address - Country:US
Mailing Address - Phone:808-238-9011
Mailing Address - Fax:
Practice Address - Street 1:91-213 KAIELEELE PL
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-4617
Practice Address - Country:US
Practice Address - Phone:808-238-9011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI18962164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty