Provider Demographics
NPI:1558146019
Name:CAMPBELL, KELLY D
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:D
Other - Last Name:KRAUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4824
Mailing Address - Country:US
Mailing Address - Phone:262-894-4765
Mailing Address - Fax:
Practice Address - Street 1:623 BERNARD ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-6208
Practice Address - Country:US
Practice Address - Phone:920-245-5246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17071-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist