Provider Demographics
NPI:1326828195
Name:SUDIMAK, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:SUDIMAK
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 1:109 BEARD AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-5120
Mailing Address - Country:US
Mailing Address - Phone:302-357-0168
Mailing Address - Fax:
Practice Address - Street 1:109 BEARD AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-5120
Practice Address - Country:US
Practice Address - Phone:302-357-0168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-115327-0163W00000X
MA332554174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse