Provider Demographics
NPI:1083422109
Name:MCCOLLUM, KIA DENAE
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:DENAE
Last Name:MCCOLLUM
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 1:4307 NW HOOVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-1739
Mailing Address - Country:US
Mailing Address - Phone:580-678-3687
Mailing Address - Fax:
Practice Address - Street 1:5602 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9699
Practice Address - Country:US
Practice Address - Phone:580-581-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK220894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily