Provider Demographics
NPI:1467163782
Name:VARGAS PULLIQUITIN ELLEGARD, JOSSELYN JEANNETH
Entity Type:Individual
Prefix:
First Name:JOSSELYN
Middle Name:JEANNETH
Last Name:VARGAS PULLIQUITIN ELLEGARD
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:PO BOX 258
Mailing Address - Street 2:
Mailing Address - City:KALAHEO
Mailing Address - State:HI
Mailing Address - Zip Code:96741-0258
Mailing Address - Country:US
Mailing Address - Phone:808-652-7379
Mailing Address - Fax:
Practice Address - Street 1:3-3122 KUHIO HWY STE A15
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1157
Practice Address - Country:US
Practice Address - Phone:808-246-9102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician