Provider Demographics
NPI:1346511979
Name:WANNEMILLER, MYIA
Entity Type:Individual
Prefix:
First Name:MYIA
Middle Name:
Last Name:WANNEMILLER
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 1:258 HOALIKE ST
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:258 HOALIKE ST
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7009
Practice Address - Country:US
Practice Address - Phone:808-875-0388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI9321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical