Provider Demographics
NPI:1518019769
Name:CAMPBELL, KATHLEEN SUSAN (PAC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SUSAN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 TILLEY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4440
Mailing Address - Country:US
Mailing Address - Phone:802-847-7063
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:125BA3
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-8675
Practice Address - Fax:802-847-2311
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010548-1363AM0700X
VT055-0030834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTS62585Medicare UPIN