Provider Demographics
NPI:1487976486
Name:CAMPBELL, KELLY (LPN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 43RD ST
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-1121
Mailing Address - Country:US
Mailing Address - Phone:631-608-8363
Mailing Address - Fax:
Practice Address - Street 1:461 43RD ST
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-1121
Practice Address - Country:US
Practice Address - Phone:631-608-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296116-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse