Healthcare Provider Details

I. General information

NPI: 1780955260
Provider Name (Legal Business Name): MS. KRISHANA LEIGH-ANNE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2012
Last Update Date: 01/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 PINEHAVEN STREET EXT
LAURENS SC
29360-2672
US

IV. Provider business mailing address

379 PINEHAVEN STREET EXT
LAURENS SC
29360-2672
US

V. Phone/Fax

Practice location:
  • Phone: 864-984-6584
  • Fax: 864-984-6464
Mailing address:
  • Phone: 864-984-6584
  • Fax: 864-984-6464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2715
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: