Provider Demographics
NPI:1366513418
Name:BOHANNON, SUSAN INA (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:INA
Last Name:BOHANNON
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
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 790326
Mailing Address - Street 2:
Mailing Address - City:PAIA
Mailing Address - State:HI
Mailing Address - Zip Code:96779-0326
Mailing Address - Country:US
Mailing Address - Phone:808-572-2115
Mailing Address - Fax:
Practice Address - Street 1:69 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1611
Practice Address - Country:US
Practice Address - Phone:808-244-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT 6806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIMAT 6806OtherMASSAGE THERAPIST #