Provider Demographics
NPI:1811560063
Name:FENTON, ELIZABETH (LMT)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:FENTON
Suffix:
Gender:F
Credentials:LMT
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 1026
Mailing Address - Street 2:
Mailing Address - City:VOLCANO
Mailing Address - State:HI
Mailing Address - Zip Code:96785-1026
Mailing Address - Country:US
Mailing Address - Phone:808-365-6818
Mailing Address - Fax:
Practice Address - Street 1:11-2518 KOKOKAHI ROAD
Practice Address - Street 2:
Practice Address - City:VOLCANO
Practice Address - State:HI
Practice Address - Zip Code:96785
Practice Address - Country:US
Practice Address - Phone:808-365-6818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT12004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty