Provider Demographics
NPI:1235124017
Name:HOLLAND, KIM RAYE (ARNP)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:RAYE
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502-0785
Mailing Address - Country:US
Mailing Address - Phone:580-357-9984
Mailing Address - Fax:580-357-3277
Practice Address - Street 1:2601 W ELK AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1572
Practice Address - Country:US
Practice Address - Phone:580-251-6644
Practice Address - Fax:580-251-6645
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0051232363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200051370AMedicaid
OK175194700OtherDOL