Provider Demographics
NPI:1659581676
Name:NELSON, CHRISTINE LEISHMAN (SSW)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LEISHMAN
Last Name:NELSON
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:LEISHMAN
Other - Suffix:
Other - Last Name Type:Former Name
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:808-326-5629
Mailing Address - Fax:
Practice Address - Street 1:75-5751 KUAKINI HWY STE 101A
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1705
Practice Address - Country:US
Practice Address - Phone:808-326-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT281934-1206363A00000X
MO2022013877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT281934-3503OtherSTATE LICENSE
UTNELSOCOtherSBHC STAFF CODE