Provider Demographics
NPI:1154985331
Name:JIM, TEODORA (LPN)
Entity type:Individual
Prefix:
First Name:TEODORA
Middle Name:
Last Name:JIM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-450 MOKUOLA ST STE 100
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3388
Mailing Address - Country:US
Mailing Address - Phone:808-944-2882
Mailing Address - Fax:
Practice Address - Street 1:3440 LEAHI AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-4235
Practice Address - Country:US
Practice Address - Phone:808-733-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI7267164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse