Healthcare Provider Details

I. General information

NPI: 1134525546
Provider Name (Legal Business Name): DEBRA KETTLESON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PONAHAWAI ST STE 221
HILO HI
96720-7829
US

IV. Provider business mailing address

670 PONAHAWAI ST STE 221
HILO HI
96720-7829
US

V. Phone/Fax

Practice location:
  • Phone: 808-365-5988
  • Fax: 808-365-5989
Mailing address:
  • Phone: 808-365-5988
  • Fax: 808-365-5989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0381075
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number2009004214
License Number StateHI

VIII. Authorized Official

Name: DEBRA LYNN KETTLESON
Title or Position: OWNER/PROVIDER
Credential:
Phone: 808-365-5988