Healthcare Provider Details

I. General information

NPI: 1053101352
Provider Name (Legal Business Name): KELLIE LYNN CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NOVELL PL
PROVO UT
84606-6171
US

IV. Provider business mailing address

1800 NOVELL PL
PROVO UT
84606-6171
US

V. Phone/Fax

Practice location:
  • Phone: 801-375-5125
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110012371
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: