Provider Demographics
NPI:1376350306
Name:CORPUZ, SHANE LYKA
Entity type:Individual
Prefix:
First Name:SHANE LYKA
Middle Name:
Last Name:CORPUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-1167 KAHUAINA ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3406
Mailing Address - Country:US
Mailing Address - Phone:808-497-2353
Mailing Address - Fax:
Practice Address - Street 1:45-090 NAMOKU ST
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-5305
Practice Address - Country:US
Practice Address - Phone:808-497-2353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOTA-332224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant