Provider Demographics
NPI:1891320800
Name:MCTIGUE, SALLY JO (APRN-RX)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JO
Last Name:MCTIGUE
Suffix:
Gender:F
Credentials:APRN-RX
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2154
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-8154
Mailing Address - Country:US
Mailing Address - Phone:088-818-7031
Mailing Address - Fax:808-207-3507
Practice Address - Street 1:1314 S KING ST STE 723
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1942
Practice Address - Country:US
Practice Address - Phone:808-818-7031
Practice Address - Fax:808-818-7031
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28059363LF0000X
HIAPRN-2852363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIAPRN2852OtherHAWAII LICENSE