MEDICARE: CHANELLE LYNN PUALLILIA KEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency	47-3166133	HI
2	251E00000X	Home Health Agency	47-3166133	HI
3	251J00000X	Nursing Care Agency	47-3166133	HI
4	251S00000X	Community/Behavioral Health Agency	47-3166133	HI
5	253J00000X	Foster Care Agency	47-3166133	HI
6	253Z00000X	In Home Supportive Care Agency	47-3166133	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215321112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANELLE LYNN PUALLILIA KEY

Provider Business Mailing Address
First Line	:	PO BOX 22714
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96823-2714
Country	:	US
Telephone Number	:	808-450-8897
Fax Number	:

Provider Business Practice Location Address
First Line	:	2221 ANIANIKU ST
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96813-1406
Country	:	US
Telephone Number	:	808-450-8897
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2015
Last Update Date	:	03/27/2015

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