Provider Demographics
NPI:1255920690
Name:KELLOGG, COLLYN MICHAEL
Entity type:Individual
Prefix:
First Name:COLLYN
Middle Name:MICHAEL
Last Name:KELLOGG
Suffix:
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 1:913 W MAIN ST APT 518
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-7918
Mailing Address - Country:US
Mailing Address - Phone:713-213-8060
Mailing Address - Fax:
Practice Address - Street 1:913 W MAIN ST APT 518
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-7918
Practice Address - Country:US
Practice Address - Phone:713-213-8060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program