Provider Demographics
NPI:1851750194
Name:MELLON, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MELLON
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 1:2-2514 KAUMUALII HWY
Mailing Address - Street 2:#21
Mailing Address - City:KALAHEO
Mailing Address - State:HI
Mailing Address - Zip Code:96741-8303
Mailing Address - Country:US
Mailing Address - Phone:808-332-5580
Mailing Address - Fax:808-332-5583
Practice Address - Street 1:2-2514 KAUMUALII HWY
Practice Address - Street 2:#21
Practice Address - City:KALAHEO
Practice Address - State:HI
Practice Address - Zip Code:96741-8303
Practice Address - Country:US
Practice Address - Phone:808-332-5580
Practice Address - Fax:808-332-5583
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU-314171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist