Provider Demographics
NPI:1023882081
Name:BOLO, CARISSA MANREAL (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:MANREAL
Last Name:BOLO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1030 HOKUA PL
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-4899
Mailing Address - Country:US
Mailing Address - Phone:808-382-2276
Mailing Address - Fax:
Practice Address - Street 1:91-1030 HOKUA PL
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-4899
Practice Address - Country:US
Practice Address - Phone:808-382-2276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-4297363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health