Basic Information
| Provider Information | |||||||||
| NPI: | 1205807625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACKERMANN | ||||||||
| FirstName: | BETTINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 MAHALANI ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967932526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082449056 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 221 MAHALANI ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967932526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082449056 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD421508 | PA | N | Other Service Providers | Specialist | 208000000X | MD-14181 | HI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 001965840 | 05 | PA | MEDICAID |