Provider Demographics
NPI:1992206973
Name:CORREA, CARLY KALEO (APRN-RX)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:KALEO
Last Name:CORREA
Suffix:
Gender:F
Credentials:APRN-RX
Other - Prefix:
Other - First Name:KALEO
Other - Middle Name:
Other - Last Name:CORREA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN-RX
Mailing Address - Street 1:65-1298B KAWAIHAE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-7342
Mailing Address - Country:US
Mailing Address - Phone:808-731-5003
Mailing Address - Fax:808-731-4330
Practice Address - Street 1:65-1298B KAWAIHAE RD STE 3
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-7342
Practice Address - Country:US
Practice Address - Phone:808-731-5003
Practice Address - Fax:808-731-4330
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-2394363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
14214954OtherCAQH
HIAPRN2394OtherAPRN LICENSE
HIAPRN2394OtherAPRN LICENSE