Provider Demographics
NPI:1518252634
Name:DOUGHERTY, SUSANNA DANI ELECTA (CPM, LM, PCES)
Entity Type:Individual
Prefix:
First Name:SUSANNA DANI
Middle Name:ELECTA
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:CPM, LM, PCES
Other - Prefix:
Other - First Name:SUSANNA DANI
Other - Middle Name:ELECTA
Other - Last Name:KENENDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPM, LM
Mailing Address - Street 1:PO BOX 551794
Mailing Address - Street 2:
Mailing Address - City:KAPAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96755-1794
Mailing Address - Country:US
Mailing Address - Phone:808-990-0394
Mailing Address - Fax:
Practice Address - Street 1:40 POHAKULANI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3116
Practice Address - Country:US
Practice Address - Phone:808-990-0394
Practice Address - Fax:888-977-3122
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
HIMW-9176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIMW-9OtherHAWAII LICENCE NUMBER