Provider Demographics
NPI:1215222443
Name:TAKARA, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:TAKARA
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 1:1700 LANAKILA AVE
Mailing Address - Street 2:RM 210
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 LANAKILA AVE
Practice Address - Street 2:RM 210
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2115
Practice Address - Country:US
Practice Address - Phone:808-832-5688
Practice Address - Fax:808-832-5698
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOT-632172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker