Basic Information
| Provider Information | |||||||||
| NPI: | 1972822047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUKLIS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 677 ALA MOANA BLVD STE 1001 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968135408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084694900 | ||||||||
| FaxNumber: | 8085367315 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 W KAWILI ST | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967205098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087980196 | ||||||||
| FaxNumber: | 8085367315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN-66187 | HI | N | Nursing Service Providers | Registered Nurse | 363LF0000X | APRN-2395 | HI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | HH2711 | 05 | AK | MEDICAID | MS0272 | 05 | AK | MEDICAID | CMG799 | 05 | AK | MEDICAID | NA3799 | 05 | AK | MEDICAID | HC2563 | 05 | AK | MEDICAID |