Provider Demographics
NPI:1134808272
Name:COLLIER, KENNETH WAYNE JR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:COLLIER
Suffix:JR
Gender:M
Credentials:
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 13353
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45413-0353
Mailing Address - Country:US
Mailing Address - Phone:937-672-0894
Mailing Address - Fax:
Practice Address - Street 1:2554 NEEDMORE RD # C2
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-4204
Practice Address - Country:US
Practice Address - Phone:937-672-0894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH114336146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic