Provider Demographics
NPI:1841757978
Name:WIMBERLEY, MICHELLE LEIGHANN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIGHANN
Last Name:WIMBERLEY
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 1:91-1016 KAIMOANA ST
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-6074
Mailing Address - Country:US
Mailing Address - Phone:808-222-0047
Mailing Address - Fax:
Practice Address - Street 1:909 HAUMEA ST
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2044
Practice Address - Country:US
Practice Address - Phone:808-674-3523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAT-3342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer