Provider Demographics
NPI:1114616380
Name:CAMPBELL, KELLY MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4609 SW GOSSAMER CIR
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-1552
Mailing Address - Country:US
Mailing Address - Phone:561-568-8404
Mailing Address - Fax:
Practice Address - Street 1:2402 FRIST BLVD STE 201
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4838
Practice Address - Country:US
Practice Address - Phone:772-460-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9267220163W00000X
FL11027380363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse