Provider Demographics
NPI:1215189048
Name:FANUA, JOE
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:FANUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 WAIMANO HOME RD
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-1478
Mailing Address - Country:US
Mailing Address - Phone:808-454-1411
Mailing Address - Fax:
Practice Address - Street 1:2501 WAIMANO HOME RD
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-1478
Practice Address - Country:US
Practice Address - Phone:808-454-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health