Provider Demographics
NPI:1649534884
Name:HERMOSURA, SHAUNNA DEZRAE KAMANU'ENA (OTR/L)
Entity type:Individual
Prefix:
First Name:SHAUNNA
Middle Name:DEZRAE KAMANU'ENA
Last Name:HERMOSURA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KAMANU
Other - Middle Name:
Other - Last Name:MAUNUPAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:94-164 KUPUOHI PL
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-1122
Mailing Address - Country:US
Mailing Address - Phone:808-306-5029
Mailing Address - Fax:
Practice Address - Street 1:860 4TH ST STE 150
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-3690
Practice Address - Country:US
Practice Address - Phone:808-453-6960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QX0100X
HIOT1120225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine