1710566484 NPI number — MRS. ROXAN JUNA LEE SIMON MANZANO RN

Table of content: MRS. ROXAN JUNA LEE SIMON MANZANO RN (NPI 1710566484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710566484 NPI number — MRS. ROXAN JUNA LEE SIMON MANZANO RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANZANO
Provider First Name:
ROXAN JUNA LEE
Provider Middle Name:
SIMON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
UMAYAM
Provider Other First Name:
ROXAN JUNA LEE
Provider Other Middle Name:
SIMON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710566484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
94-530 KOALEO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAIPAHU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96797-1634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-352-2652
Provider Business Mailing Address Fax Number:
808-517-4251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
94-530 KOALEO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAIPAHU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96797-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-352-2652
Provider Business Practice Location Address Fax Number:
808-517-4251
Provider Enumeration Date:
04/07/2021

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: 163WW0000X , with the licence number:  79319 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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