1518252634 NPI number — SUSANNA DANI ELECTA DOUGHERTY CPM, LM, PCES

Table of content: ARIEL SHANTRICE WILSON (NPI 1720644008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518252634 NPI number — SUSANNA DANI ELECTA DOUGHERTY CPM, LM, PCES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGHERTY
Provider First Name:
SUSANNA DANI
Provider Middle Name:
ELECTA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPM, LM, PCES
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KENENDY
Provider Other First Name:
SUSANNA DANI
Provider Other Middle Name:
ELECTA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CPM, LM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518252634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 551794
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KAPAAU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96755-1794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-990-0394
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 POHAKULANI ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILO
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96720-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-990-0394
Provider Business Practice Location Address Fax Number:
888-977-3122
Provider Enumeration Date:
06/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 176B00000X , with the licence number: MW-9 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MW-9 . This is a "HAWAII LICENCE NUMBER" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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