Healthcare Provider Details

I. General information

NPI: 1912415548
Provider Name (Legal Business Name): SUERTE CORLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5113 MAUNALANI CIR
HONOLULU HI
96816-4019
US

IV. Provider business mailing address

94-1064 HIAPO ST
WAIPAHU HI
96797-3708
US

V. Phone/Fax

Practice location:
  • Phone: 808-695-2830
  • Fax:
Mailing address:
  • Phone: 808-498-7366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN69561
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN69561
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: