Provider Demographics
NPI:1134590508
Name:WONG, AMANDA M L (APRN, AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M L
Last Name:WONG
Suffix:
Gender:F
Credentials:APRN, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 IHOLENA ST APT B
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 S BERETANIA ST STE 601
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2423
Practice Address - Country:US
Practice Address - Phone:808-691-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-1924363LA2200X, 364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology