Healthcare Provider Details

I. General information

NPI: 1417278557
Provider Name (Legal Business Name): CRYSTAL KIXMILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 HOPPE BLVD STE 6
ADA OK
74820-2319
US

IV. Provider business mailing address

PO BOX 1710
KINGSTON OK
73439-1710
US

V. Phone/Fax

Practice location:
  • Phone: 580-235-0274
  • Fax:
Mailing address:
  • Phone: 580-564-7374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: