Healthcare Provider Details

I. General information

NPI: 1659968410
Provider Name (Legal Business Name): PENNEY PUANANI OGUMA BA, CDCS,CSAC, ICADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 08/27/2022
Certification Date: 08/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 KATY JILL CT
NORTH POLE AK
99705-5640
US

IV. Provider business mailing address

1521 KATY JILL CT
NORTH POLE AK
99705-5640
US

V. Phone/Fax

Practice location:
  • Phone: 808-673-9750
  • Fax:
Mailing address:
  • Phone: 808-673-9750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1880-15
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: