Healthcare Provider Details

I. General information

NPI: 1700843372
Provider Name (Legal Business Name): NICOLE M KORANDA OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE WILLETTE OTRL

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64-957 MAMALAHOA HWY
KAMUELA HI
96743-8415
US

IV. Provider business mailing address

PO BOX 2765
KAMUELA HI
96743-2765
US

V. Phone/Fax

Practice location:
  • Phone: 808-209-7934
  • Fax: 808-883-6262
Mailing address:
  • Phone: 808-209-7934
  • Fax: 808-883-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number992
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: