Provider Demographics
NPI:1528737079
Name:MOORE, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:MOORE
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:PO BOX 1691
Mailing Address - Street 2:
Mailing Address - City:KAPAA
Mailing Address - State:HI
Mailing Address - Zip Code:96746-5691
Mailing Address - Country:US
Mailing Address - Phone:808-631-5865
Mailing Address - Fax:
Practice Address - Street 1:4800 KAWAIHAU RD
Practice Address - Street 2:
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1971
Practice Address - Country:US
Practice Address - Phone:808-631-5865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty