Provider Demographics
NPI:1679161665
Name:NEILSON, LEANN
Entity type:Individual
Prefix:
First Name:LEANN
Middle Name:
Last Name:NEILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:HI
Mailing Address - Zip Code:96771-0162
Mailing Address - Country:US
Mailing Address - Phone:808-796-1258
Mailing Address - Fax:
Practice Address - Street 1:18-1228 KONA ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:HI
Practice Address - Zip Code:96771-9677
Practice Address - Country:US
Practice Address - Phone:808-796-1258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3107363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health