Provider Demographics
NPI:1407914047
Name:CAMPBELL, KATHLEEN M (DOM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 N LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-4246
Mailing Address - Country:US
Mailing Address - Phone:505-388-1824
Mailing Address - Fax:
Practice Address - Street 1:1401 N LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-4246
Practice Address - Country:US
Practice Address - Phone:505-388-1824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM168171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00RE90OtherBLUE CROSS BLUE SHIELD