Healthcare Provider Details

I. General information

NPI: 1518026467
Provider Name (Legal Business Name): KATHLEEN FANSHAW IANNITELLO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MAHALANI ST
WAILUKU HI
96793-2528
US

IV. Provider business mailing address

570 MAALAHI ST
WAILUKU HI
96793-1541
US

V. Phone/Fax

Practice location:
  • Phone: 808-984-2150
  • Fax: 808-984-2155
Mailing address:
  • Phone: 808-244-0961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD5702
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: