Healthcare Provider Details

I. General information

NPI: 1699062570
Provider Name (Legal Business Name): AMY GENEE PETERSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/13/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 HOOHANA ST STE F
KAHULUI HI
96732-3527
US

IV. Provider business mailing address

335 HOOHANA ST STE F
KAHULUI HI
96732-3527
US

V. Phone/Fax

Practice location:
  • Phone: 808-446-2032
  • Fax: 833-565-3144
Mailing address:
  • Phone: 808-446-2032
  • Fax: 833-565-3144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 3395
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT 3395
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: