Provider Demographics
NPI:1114656733
Name:CLARK, HAYLEY ROSE (LAC)
Entity type:Individual
Prefix:MS
First Name:HAYLEY
Middle Name:ROSE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53-480 KAMEHAMEHA HWY APT G
Mailing Address - Street 2:
Mailing Address - City:HAUULA
Mailing Address - State:HI
Mailing Address - Zip Code:96717-9717
Mailing Address - Country:US
Mailing Address - Phone:609-206-4316
Mailing Address - Fax:
Practice Address - Street 1:114 MAIN CAMP
Practice Address - Street 2:
Practice Address - City:KAHUKU
Practice Address - State:HI
Practice Address - Zip Code:96731
Practice Address - Country:US
Practice Address - Phone:609-206-4316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1346171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIBEZ-AAC-1001OtherAMERICAN ACUPUNCTURE COUNCIL