Provider Demographics
NPI:1306015342
Name:CAMPBELL, VONDA K (PTA)
Entity Type:Individual
Prefix:
First Name:VONDA
Middle Name:K
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 MARYLAND AVE
Mailing Address - Street 2:APT 328
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2737
Mailing Address - Country:US
Mailing Address - Phone:636-734-5993
Mailing Address - Fax:
Practice Address - Street 1:4355 MARYLAND AVE
Practice Address - Street 2:APT 328
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2737
Practice Address - Country:US
Practice Address - Phone:636-734-5993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116460225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant