Provider Demographics
NPI:1457100299
Name:ENBOM, ALYSHA DELPHINE
Entity type:Individual
Prefix:
First Name:ALYSHA
Middle Name:DELPHINE
Last Name:ENBOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSHA
Other - Middle Name:DELPHINE
Other - Last Name:HARTSHORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 624
Mailing Address - Street 2:
Mailing Address - City:HANAPEPE
Mailing Address - State:HI
Mailing Address - Zip Code:96716-0624
Mailing Address - Country:US
Mailing Address - Phone:360-301-5568
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 624
Practice Address - Street 2:
Practice Address - City:HANAPEPE
Practice Address - State:HI
Practice Address - Zip Code:96716-0624
Practice Address - Country:US
Practice Address - Phone:360-301-5568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55667163W00000X
WARN61092439163W00000X
HI103027163W00000X
HIAPRN-4642363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse