Provider Demographics
NPI:1801131149
Name:BOUSTANI, JAMIE V (LAC)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:V
Last Name:BOUSTANI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:L
Other - Last Name:VARELA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:122 KAPUAHI ST.
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768
Mailing Address - Country:US
Mailing Address - Phone:808-633-6581
Mailing Address - Fax:808-579-8885
Practice Address - Street 1:16 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:PAIA
Practice Address - State:HI
Practice Address - Zip Code:96779
Practice Address - Country:US
Practice Address - Phone:808-633-6581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1045171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist