Provider Demographics
NPI:1922478593
Name:KANDRA, NICOLE ANNE (ATC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNE
Last Name:KANDRA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 LUKEPANE AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-1001
Mailing Address - Country:US
Mailing Address - Phone:541-591-4719
Mailing Address - Fax:
Practice Address - Street 1:1337 LOWER CAMPUS RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822-2352
Practice Address - Country:US
Practice Address - Phone:808-956-7144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer