Provider Demographics
NPI:1871759050
Name:FACHINELLI PORTES, VICKIE MARIE (RN,CNP)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:MARIE
Last Name:FACHINELLI PORTES
Suffix:
Gender:F
Credentials:RN,CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5751 KUAKINI HWY STE 203
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1753
Mailing Address - Country:US
Mailing Address - Phone:808-333-3600
Mailing Address - Fax:808-961-5167
Practice Address - Street 1:16-192 PILI MUA ST
Practice Address - Street 2:
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749-8134
Practice Address - Country:US
Practice Address - Phone:808-333-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1399752363LP0200X
HIAPRN-2904208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500006830Medicare PIN