Provider Demographics
NPI:1710344460
Name:WYATT, KATHLEEN (RN, MSN, MBA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:RN, MSN, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98-1247 KAAHUMANU ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5311
Mailing Address - Country:US
Mailing Address - Phone:808-798-8706
Mailing Address - Fax:808-691-9027
Practice Address - Street 1:98-1247 KAAHUMANU ST
Practice Address - Street 2:SUITE 207
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-5311
Practice Address - Country:US
Practice Address - Phone:808-798-8706
Practice Address - Fax:808-691-9027
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1-0615261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care