Provider Demographics
NPI:1376898858
Name:POPP, MICHELLE DIANE (LMT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:DIANE
Last Name:POPP
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5656 KUAKINI HWY STE 101B
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1673
Mailing Address - Country:US
Mailing Address - Phone:808-430-0129
Mailing Address - Fax:808-326-9858
Practice Address - Street 1:75-5656 KUAKINI HWY STE 101B
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1673
Practice Address - Country:US
Practice Address - Phone:808-430-0129
Practice Address - Fax:808-326-9858
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT 4577225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist