Provider Demographics
NPI:1134488109
Name:LEIATAUA, KANANI ELIZABETH
Entity Type:Individual
Prefix:
First Name:KANANI
Middle Name:ELIZABETH
Last Name:LEIATAUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 W WHITING AVE
Mailing Address - Street 2:UNIT F
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1464
Mailing Address - Country:US
Mailing Address - Phone:714-722-1599
Mailing Address - Fax:
Practice Address - Street 1:100 E VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1321
Practice Address - Country:US
Practice Address - Phone:714-680-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD1151627171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator