Provider Demographics
NPI:1396209706
Name:WULZEN, RENEE LEIOKAMALIA
Entity Type:Individual
Prefix:MISS
First Name:RENEE
Middle Name:LEIOKAMALIA
Last Name:WULZEN
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:PO BOX 1890
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-1890
Mailing Address - Country:US
Mailing Address - Phone:808-333-7647
Mailing Address - Fax:
Practice Address - Street 1:IRONWOOD CENTER SUITE 106
Practice Address - Street 2:64-5193 KINOHOU STREET
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743
Practice Address - Country:US
Practice Address - Phone:808-333-7647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11026225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist