Basic Information
| Provider Information | |||||||||
| NPI: | 1497788012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967931666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082426464 | ||||||||
| FaxNumber: | 8082424209 | ||||||||
| Practice Location | |||||||||
| Address1: | 2180 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAILUKU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967931666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082426464 | ||||||||
| FaxNumber: | 8082424209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 05/30/2017 | ||||||||
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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 | 363L00000X | APRN827 | HI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP2300X | 201703379NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 99017685996768 | 01 | HI | TRICARE- CHAMPUS | OTHER | 0257493 | 01 | HI | HMSA - 65CP - HMSA QUEST | OTHER | 431043 | 01 | HI | UHA | OTHER |