Provider Demographics
NPI:1730125543
Name:SALLE, NADINE TENN (MD)
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:TENN
Last Name:SALLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 SIERRA DR
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-3342
Mailing Address - Country:US
Mailing Address - Phone:808-521-9404
Mailing Address - Fax:808-521-9406
Practice Address - Street 1:550 S BERETANIA ST
Practice Address - Street 2:STE 502
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2496
Practice Address - Country:US
Practice Address - Phone:808-521-9404
Practice Address - Fax:808-521-9406
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11321MD207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI507510-02Medicaid
54599Medicare ID - Type Unspecified
HI507510-02Medicaid