Provider Demographics
NPI:1376038505
Name:GLICK, STEPHANIE K (CRNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:K
Last Name:GLICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5751 KUAKINI HWY
Mailing Address - Street 2:STE 203
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1753
Mailing Address - Country:US
Mailing Address - Phone:808-660-2593
Mailing Address - Fax:808-553-5194
Practice Address - Street 1:75-5751 KUAKINI HWY STE 101A
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1705
Practice Address - Country:US
Practice Address - Phone:808-326-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018948363LF0000X
HIAPRN-2691363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily