Healthcare Provider Details

I. General information

NPI: 1487053609
Provider Name (Legal Business Name): KIMBERLY CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2129 WEST STREET SUITE 224
GERMANTOWN TN
38138
US

IV. Provider business mailing address

2129 WEST STREET SUITE 224
GERMANTOWN TN
38138
US

V. Phone/Fax

Practice location:
  • Phone: 866-563-7772
  • Fax: 901-255-0758
Mailing address:
  • Phone: 866-563-7772
  • Fax: 901-255-0758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2239
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: