Provider Demographics
NPI:1689471963
Name:DIEDEERICH, ELISHA FAWN
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:FAWN
Last Name:DIEDEERICH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12-7004 HOKUAO ST # 50
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-7892
Mailing Address - Country:US
Mailing Address - Phone:808-557-8807
Mailing Address - Fax:
Practice Address - Street 1:12-7004 HOKUAO ST # 50
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-7892
Practice Address - Country:US
Practice Address - Phone:808-557-8807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-8824225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist