Provider Demographics
NPI:1073686630
Name:PARK, KELLY ANN FUMIE (DPT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN FUMIE
Last Name:PARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W HIND DR
Mailing Address - Street 2:SUITE 104 AND 108
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96821-1855
Mailing Address - Country:US
Mailing Address - Phone:808-373-4787
Mailing Address - Fax:
Practice Address - Street 1:850 W HIND DR
Practice Address - Street 2:SUITE 104 AND 108
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96821-1855
Practice Address - Country:US
Practice Address - Phone:808-373-4787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000255364OtherHMSA QUEST PROV. NUMBER
HI0000255364OtherHMSA PROVIDER NUMBER
HI2695487OtherUNIVERSITY HEALTH ALLIANC
HI57436001Medicaid
HI57436001Medicaid