Healthcare Provider Details

I. General information

NPI: 1053293639
Provider Name (Legal Business Name): MEGAN MARIE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2025
Last Update Date: 07/23/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 VARELLA AVE
ST AUGUSTINE FL
32084-2096
US

IV. Provider business mailing address

13990 BARTRAM PARK BLVD UNIT 2621
JACKSONVILLE FL
32258-5578
US

V. Phone/Fax

Practice location:
  • Phone: 904-547-8530
  • Fax:
Mailing address:
  • Phone: 904-318-9873
  • Fax: 904-318-9873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: