Healthcare Provider Details

I. General information

NPI: 1336117258
Provider Name (Legal Business Name): KELLY A CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY A WADE

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 FARENHOLT AVE BLDG 14 RM 230
SAN DIEGO CA
92134-5291
US

IV. Provider business mailing address

34101 FARENHOLT AVE BLDG 14 RM 230
SAN DIEGO CA
92134-5291
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-5104
  • Fax:
Mailing address:
  • Phone: 619-532-5104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: