Provider Demographics
NPI:1821322355
Name:WEISSBACH, LAURA LEE HENDRICKS
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE HENDRICKS
Last Name:WEISSBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LEE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3027 PUALEI CIR APT 209
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-4969
Mailing Address - Country:US
Mailing Address - Phone:808-927-5899
Mailing Address - Fax:
Practice Address - Street 1:2828 PAA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-4430
Practice Address - Country:US
Practice Address - Phone:808-432-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-54391163W00000X
HIAPRN-1133363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse