Provider Demographics
NPI:1538898523
Name:CANLAS, JUDY HERMOSURA
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:HERMOSURA
Last Name:CANLAS
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 1:94-534 HAKEA PL
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-4761
Mailing Address - Country:US
Mailing Address - Phone:808-779-6187
Mailing Address - Fax:808-200-5938
Practice Address - Street 1:94-534 HAKEA PL
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-4761
Practice Address - Country:US
Practice Address - Phone:808-779-6187
Practice Address - Fax:808-200-5938
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1-200077311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI000848Medicaid