Provider Demographics
NPI:1518026467
Name:IANNITELLO, KATHLEEN FANSHAW (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:FANSHAW
Last Name:IANNITELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 MAALAHI ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1541
Mailing Address - Country:US
Mailing Address - Phone:808-244-0961
Mailing Address - Fax:
Practice Address - Street 1:121 MAHALANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2528
Practice Address - Country:US
Practice Address - Phone:808-984-2150
Practice Address - Fax:808-984-2155
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD57022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI51655OtherALOHA CARE
HI53937204Medicaid
HI56288Medicare ID - Type Unspecified
HI53937204Medicaid