Provider Demographics
NPI:1558128348
Name:CAMPBELL, KELLY M (RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 BLACKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-6960
Mailing Address - Country:US
Mailing Address - Phone:540-968-2530
Mailing Address - Fax:
Practice Address - Street 1:5800 BLACKSBURG RD
Practice Address - Street 2:
Practice Address - City:TROUTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24175-6960
Practice Address - Country:US
Practice Address - Phone:540-968-2530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86032191133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered