Basic Information
| Provider Information | |||||||||
| NPI: | 1225170020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALVERT | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | NOELLE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95-624 MAKAIMOIMO ST | ||||||||
| Address2: | |||||||||
| City: | MILILANI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967892921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086251448 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 932 WARD AVE | ||||||||
| Address2: | 7TH FLOOR | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968142131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083818947 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-2051 | HI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0000254821 | 01 | HI | HMSA | OTHER |