Provider Demographics
NPI:1467629725
Name:DEMELLO-O'BANNON, PAULLA
Entity Type:Individual
Prefix:
First Name:PAULLA
Middle Name:
Last Name:DEMELLO-O'BANNON
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 390940
Mailing Address - Street 2:
Mailing Address - City:KEAUHOU
Mailing Address - State:HI
Mailing Address - Zip Code:96739-0940
Mailing Address - Country:US
Mailing Address - Phone:808-896-5064
Mailing Address - Fax:808-322-4817
Practice Address - Street 1:79-1020 HAUKAPILA ST
Practice Address - Street 2:
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750-7922
Practice Address - Country:US
Practice Address - Phone:808-322-4818
Practice Address - Fax:808-322-4817
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539372-18Medicaid