Healthcare Provider Details

I. General information

NPI: 1326942616
Provider Name (Legal Business Name): LIANA MARIE BROUILLETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 WAIANUENUE AVE
HILO HI
96720-2446
US

IV. Provider business mailing address

PO BOX 688
KURTISTOWN HI
96760-0688
US

V. Phone/Fax

Practice location:
  • Phone: 808-731-5544
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAMD-1589-0
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: