1497096044 NPI number — MRS. TRYSHA LEINANI MISA BODDEN M.A.

Table of content: MRS. TRYSHA LEINANI MISA BODDEN M.A. (NPI 1497096044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497096044 NPI number — MRS. TRYSHA LEINANI MISA BODDEN M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BODDEN
Provider First Name:
TRYSHA
Provider Middle Name:
LEINANI MISA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497096044
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
91-2032 KAIOLI ST APT 6001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EWA BEACH
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96706-6081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 N NIMITZ HWY RM A203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96817-5785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-294-5810
Provider Business Practice Location Address Fax Number:
808-441-7744
Provider Enumeration Date:
03/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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