Provider Demographics
NPI:1053955914
Name:CLEVENGER, KELTIE J'NAI
Entity type:Individual
Prefix:
First Name:KELTIE
Middle Name:J'NAI
Last Name:CLEVENGER
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:PO BOX 1724
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-5724
Mailing Address - Country:US
Mailing Address - Phone:808-755-5751
Mailing Address - Fax:
Practice Address - Street 1:4-820 KUHIO HWY STE C-3
Practice Address - Street 2:
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1588
Practice Address - Country:US
Practice Address - Phone:808-755-5751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI16210225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty