Provider Demographics
NPI:1689865123
Name:KANESHINA, PENNY LOU (R D)
Entity type:Individual
Prefix:MRS
First Name:PENNY LOU
Middle Name:
Last Name:KANESHINA
Suffix:
Gender:F
Credentials:R D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MAUILANI PKWY
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2443
Mailing Address - Country:US
Mailing Address - Phone:808-856-2115
Mailing Address - Fax:808-244-5712
Practice Address - Street 1:105 MAUILANI PKWY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2443
Practice Address - Country:US
Practice Address - Phone:808-856-2115
Practice Address - Fax:808-244-5712
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRD-896071133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI56142Medicare PIN