Provider Demographics
NPI:1245337716
Name:INDA, CHRISTY LYN BOLIBOL (MS, RD)
Entity type:Individual
Prefix:
First Name:CHRISTY
Middle Name:LYN BOLIBOL
Last Name:INDA
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92-1519 PUNAWAINUI ST
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2829
Mailing Address - Country:US
Mailing Address - Phone:808-672-7246
Mailing Address - Fax:
Practice Address - Street 1:41-1347 KALANIANAOLE HWY
Practice Address - Street 2:
Practice Address - City:WAIMANALO
Practice Address - State:HI
Practice Address - Zip Code:96795-1247
Practice Address - Country:US
Practice Address - Phone:808-954-7103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI926865133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI56658Medicare ID - Type Unspecified
HIQ15301Medicare UPIN