Basic Information
Provider Information | |||||||||
NPI: | 1396173001 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAJALA | ||||||||
FirstName: | KRISTIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1190 WAIANUENUE AVENUE | ||||||||
Address2: | HILO MEDICAL CENTER - ATTN: CLINIC ADMINISTRATION | ||||||||
City: | HILO | ||||||||
State: | HI | ||||||||
PostalCode: | 967202020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8089323428 | ||||||||
FaxNumber: | 8089746723 | ||||||||
Practice Location | |||||||||
Address1: | 45 MOHOULI STREET, STE #101 | ||||||||
Address2: | HILO MEDICAL CENTER -HAWAII ISLAND FAMILY HEALTH CENTER | ||||||||
City: | HILO | ||||||||
State: | HI | ||||||||
PostalCode: | 96720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8089324215 | ||||||||
FaxNumber: | 8089339291 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2013 | ||||||||
LastUpdateDate: | 07/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1574 | HI | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TR0400X | 10094 | NE | Y |   | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation |
No ID Information.