Healthcare Provider Details

I. General information

NPI: 1669462198
Provider Name (Legal Business Name): SUSAN JOY KOHNKE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77-6346 ALII DR
KAILUA KONA HI
96740-2406
US

IV. Provider business mailing address

PO BOX 452
HOLUALOA HI
96725-0452
US

V. Phone/Fax

Practice location:
  • Phone: 443-691-9755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR136333
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN1245
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: