Healthcare Provider Details

I. General information

NPI: 1760613459
Provider Name (Legal Business Name): KELEN C MOANA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94-210 PUPUKAHI ST STE 207
WAIPAHU HI
96797-2649
US

IV. Provider business mailing address

PO BOX 325
WAIANAE HI
96792-0325
US

V. Phone/Fax

Practice location:
  • Phone: 808-554-1163
  • Fax: 808-681-1486
Mailing address:
  • Phone: 808-554-1163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMHC - 330
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: