Provider Demographics
NPI:1407348907
Name:BOURGETTE-HENRY, SANDRA
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:BOURGETTE-HENRY
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 1:98-1261 KAONOHI ST
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-2845
Mailing Address - Country:US
Mailing Address - Phone:808-389-6965
Mailing Address - Fax:
Practice Address - Street 1:98-1261 KAONOHI ST
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-2845
Practice Address - Country:US
Practice Address - Phone:808-389-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-2249363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily