Provider Demographics
NPI:1669462198
Name:KOHNKE, SUSAN JOY (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JOY
Last Name:KOHNKE
Suffix:
Gender:F
Credentials:APRN
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 452
Mailing Address - Street 2:
Mailing Address - City:HOLUALOA
Mailing Address - State:HI
Mailing Address - Zip Code:96725-0452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77-6346 ALII DR
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2406
Practice Address - Country:US
Practice Address - Phone:443-691-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR136333363LA2200X
HIAPRN1245363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP33987Medicare UPIN
MD4451C230Medicare ID - Type Unspecified