Provider Demographics
NPI:1336875384
Name:HENNEK, PATHAMA (MAT-14897)
Entity Type:Individual
Prefix:
First Name:PATHAMA
Middle Name:
Last Name:HENNEK
Suffix:
Gender:F
Credentials:MAT-14897
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 FARRINGTON HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2031
Mailing Address - Country:US
Mailing Address - Phone:808-478-2661
Mailing Address - Fax:
Practice Address - Street 1:563 FARRINGTON HWY STE 202
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2031
Practice Address - Country:US
Practice Address - Phone:808-478-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-30
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-14897225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist