Provider Demographics
NPI:1629328521
Name:GOLLA, MYRANDA SHALANE (DC)
Entity Type:Individual
Prefix:DR
First Name:MYRANDA
Middle Name:SHALANE
Last Name:GOLLA
Suffix:
Gender:F
Credentials:DC
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 3094
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-3094
Mailing Address - Country:US
Mailing Address - Phone:918-916-0444
Mailing Address - Fax:
Practice Address - Street 1:529 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5819
Practice Address - Country:US
Practice Address - Phone:918-423-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4075111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor