Provider Demographics
NPI:1396067906
Name:HOLLIS-KEENE, CYNTHIA LYNN (PMHNP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LYNN
Last Name:HOLLIS-KEENE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10520 W FARM ROAD 60
Mailing Address - Street 2:
Mailing Address - City:WALNUT GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65770-2825
Mailing Address - Country:US
Mailing Address - Phone:417-268-7952
Mailing Address - Fax:417-886-2774
Practice Address - Street 1:10520 W FARM ROAD 60
Practice Address - Street 2:
Practice Address - City:WALNUT GROVE
Practice Address - State:MO
Practice Address - Zip Code:65770-2825
Practice Address - Country:US
Practice Address - Phone:417-268-7952
Practice Address - Fax:417-886-2774
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO154542363L00000X
MO2015003170363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1396067906Medicaid
MOMA1327063Medicare PIN