Provider Demographics
NPI:1053746941
Name:LUSCOMB, KELLY LEIALOHA (NP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LEIALOHA
Last Name:LUSCOMB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 PAUAHI ST STE 101
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3043
Mailing Address - Country:US
Mailing Address - Phone:808-531-7222
Mailing Address - Fax:
Practice Address - Street 1:80 PAUAHI ST STE 101
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3043
Practice Address - Country:US
Practice Address - Phone:808-531-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-1641363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily