Healthcare Provider Details

I. General information

NPI: 1215320296
Provider Name (Legal Business Name): KIMBERLY RAE CAMPBELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2015
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 CENTRE ST
BROCKTON MA
02302-3308
US

IV. Provider business mailing address

680 CENTRE ST
BROCKTON MA
02302-3308
US

V. Phone/Fax

Practice location:
  • Phone: 508-941-7000
  • Fax: 508-941-0895
Mailing address:
  • Phone: 508-941-7000
  • Fax: 508-941-0895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5285
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: