Provider Demographics
NPI:1679148621
Name:PUAKEA, GENESIS
Entity Type:Individual
Prefix:
First Name:GENESIS
Middle Name:
Last Name:PUAKEA
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 1:16-632 OLD VOLCANO RD
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-8100
Mailing Address - Country:US
Mailing Address - Phone:808-825-3902
Mailing Address - Fax:
Practice Address - Street 1:16-632 OLD VOLCANO RD
Practice Address - Street 2:
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749-8100
Practice Address - Country:US
Practice Address - Phone:808-825-3902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty