Healthcare Provider Details

I. General information

NPI: 1518252634
Provider Name (Legal Business Name): SUSANNA DANI ELECTA DOUGHERTY CPM, LM, PCES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSANNA DANI ELECTA KENENDY CPM, LM

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 POHAKULANI ST
HILO HI
96720-3116
US

IV. Provider business mailing address

PO BOX 551794
KAPAAU HI
96755-1794
US

V. Phone/Fax

Practice location:
  • Phone: 808-990-0394
  • Fax: 888-977-3122
Mailing address:
  • Phone: 808-990-0394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW-9
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: