Healthcare Provider Details

I. General information

NPI: 1780912089
Provider Name (Legal Business Name): JUDITH CORREA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 KAPIOLANI ST
HILO HI
96720-3937
US

IV. Provider business mailing address

440 KAPIOLANI ST
HILO HI
96720-3937
US

V. Phone/Fax

Practice location:
  • Phone: 808-961-6635
  • Fax: 808-961-6434
Mailing address:
  • Phone: 808-961-6635
  • Fax: 808-961-6434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN13818
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: