Healthcare Provider Details

I. General information

NPI: 1609420793
Provider Name (Legal Business Name): MARY AGENTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2019
Last Update Date: 07/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16-204 MELEKAHIWA PL STE 3
KEAAU HI
96749-8010
US

IV. Provider business mailing address

710 GREEN ST
HONOLULU HI
96813-2119
US

V. Phone/Fax

Practice location:
  • Phone: 612-272-8724
  • Fax:
Mailing address:
  • Phone: 808-536-1015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: