Provider Demographics
NPI:1285091249
Name:TANAKA, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TANAKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 KALAWAO PL
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-1546
Mailing Address - Country:US
Mailing Address - Phone:808-445-1634
Mailing Address - Fax:
Practice Address - Street 1:2909 KALAWAO PL
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822-1546
Practice Address - Country:US
Practice Address - Phone:808-445-1634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT8377225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist