Healthcare Provider Details

I. General information

NPI: 1386270551
Provider Name (Legal Business Name): STEPHANIE MAKINO-KAHULI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1786 KINOOLE ST
HILO HI
96720-5245
US

IV. Provider business mailing address

PO BOX 6632
HILO HI
96720-8931
US

V. Phone/Fax

Practice location:
  • Phone: 808-959-5855
  • Fax: 808-959-2301
Mailing address:
  • Phone: 808-747-4862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: