Provider Demographics
NPI:1760223895
Name:PIVONKA, JENNY MARIE
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:MARIE
Last Name:PIVONKA
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 4611
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-8611
Mailing Address - Country:US
Mailing Address - Phone:808-429-9795
Mailing Address - Fax:
Practice Address - Street 1:4211 WAIALAE AVE STE 208
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-5312
Practice Address - Country:US
Practice Address - Phone:808-429-9795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-4612-0363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health