Provider Demographics
NPI:1215509872
Name:LIU, CAMELLE KAIPOLANI
Entity type:Individual
Prefix:
First Name:CAMELLE
Middle Name:KAIPOLANI
Last Name:LIU
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 1:91-1159 KEAHUMOA PKWY UNIT 3010
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-4869
Mailing Address - Country:US
Mailing Address - Phone:808-232-3119
Mailing Address - Fax:
Practice Address - Street 1:91-902 FORT WEAVER RD STE 204
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2261
Practice Address - Country:US
Practice Address - Phone:808-201-7514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI16599225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty