Healthcare Provider Details

I. General information

NPI: 1700442886
Provider Name (Legal Business Name): MICA KRISTIN HOLLOWAY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 S. ELM ST.
MOORELAND OK
73852
US

IV. Provider business mailing address

607 S. ELM ST.
MOORELAND OK
73852
US

V. Phone/Fax

Practice location:
  • Phone: 580-440-0311
  • Fax:
Mailing address:
  • Phone: 580-440-0311
  • Fax: 405-888-8744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number106039
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: