Provider Demographics
NPI:1477565745
Name:IADELUCA-MYRIANTHIS, CAROL ANN (PT, PSYD)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:IADELUCA-MYRIANTHIS
Suffix:
Gender:F
Credentials:PT, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 ALAWAENA ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3506
Mailing Address - Country:US
Mailing Address - Phone:808-959-0877
Mailing Address - Fax:
Practice Address - Street 1:15-2866 GOVERNMENT MAIN ROAD
Practice Address - Street 2:PAHOA VILLAGE CENTER
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778
Practice Address - Country:US
Practice Address - Phone:808-965-0880
Practice Address - Fax:808-965-0770
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIA19867OtherHMSA KA'U
HID19861OtherHMSA PAHOA
HI01853401Medicaid
HI01853402Medicaid
HIH0000CBBDSMedicare PIN