Provider Demographics
NPI:1629368311
Name:COFFEE, SANDRA ANN (LMT)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:ANN
Last Name:COFFEE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:SANDY
Other - Middle Name:ANN
Other - Last Name:COFFEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:64-5119 KALAKE ST
Mailing Address - Street 2:64-5119 KALAKE ST
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8201
Mailing Address - Country:US
Mailing Address - Phone:808-885-6324
Mailing Address - Fax:808-885-6324
Practice Address - Street 1:61-3616 KAWAIHAE RD
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-9721
Practice Address - Country:US
Practice Address - Phone:808-885-6324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT5246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist