Provider Demographics
NPI:1558883660
Name:CAMPBELL, KIMBERLY MAE (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MAE
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 1:1100 GRANDON WAY
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-9191
Mailing Address - Country:US
Mailing Address - Phone:717-730-4033
Mailing Address - Fax:
Practice Address - Street 1:1100 GRANDON WAY
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-9191
Practice Address - Country:US
Practice Address - Phone:717-730-4033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004466225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant