Provider Demographics
NPI:1215321112
Name:KEY, CHANELLE LYNN PUALLILIA
Entity type:Individual
Prefix:
First Name:CHANELLE
Middle Name:LYNN PUALLILIA
Last Name:KEY
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 22714
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96823-2714
Mailing Address - Country:US
Mailing Address - Phone:808-450-8897
Mailing Address - Fax:
Practice Address - Street 1:2221 ANIANIKU ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-1406
Practice Address - Country:US
Practice Address - Phone:808-450-8897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI47-3166133251C00000X, 251E00000X, 251J00000X, 251S00000X, 253J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI47-3166133Medicaid