Provider Demographics
NPI:1700843372
Name:KORANDA, NICOLE M (OTRL)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:KORANDA
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:WILLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:PO BOX 2765
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-2765
Mailing Address - Country:US
Mailing Address - Phone:808-209-7934
Mailing Address - Fax:808-883-6262
Practice Address - Street 1:64-957 MAMALAHOA HWY
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8415
Practice Address - Country:US
Practice Address - Phone:808-209-7934
Practice Address - Fax:808-883-6262
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI992225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI735277Medicaid
HP43080OtherHEALTH PARTNERRS
6400149OtherMEDICA