Provider Demographics
NPI:1093558884
Name:HOLLINS, KELLTON D'ANDRE DE'WAYNE
Entity type:Individual
Prefix:
First Name:KELLTON
Middle Name:D'ANDRE DE'WAYNE
Last Name:HOLLINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 E LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-2676
Mailing Address - Country:US
Mailing Address - Phone:580-399-5398
Mailing Address - Fax:
Practice Address - Street 1:6 E LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-2676
Practice Address - Country:US
Practice Address - Phone:580-927-3168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator