Provider Demographics
NPI:1346955762
Name:CORREA, KAYLEIGH NICOLE
Entity Type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:NICOLE
Last Name:CORREA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYLEIGH
Other - Middle Name:NICOLE
Other - Last Name:ENSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 19TH ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-4609
Mailing Address - Country:US
Mailing Address - Phone:931-999-5594
Mailing Address - Fax:
Practice Address - Street 1:1330 ALA MOANA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4262
Practice Address - Country:US
Practice Address - Phone:808-585-1424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBACB870745106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician