Provider Demographics
NPI:1134630221
Name:KOSCELEK, MENCHIE CANDA (MEDICAL TECHNOLOGIST)
Entity type:Individual
Prefix:
First Name:MENCHIE
Middle Name:CANDA
Last Name:KOSCELEK
Suffix:
Gender:F
Credentials:MEDICAL TECHNOLOGIST
Other - Prefix:
Other - First Name:MANUELA
Other - Middle Name:CANDA
Other - Last Name:KOSCELEK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:95-336 KALOAPAU ST APT 162
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-1215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95-336 KALOAPAU ST APT 162
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-1215
Practice Address - Country:US
Practice Address - Phone:808-554-2205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI900773473Medicaid