Provider Demographics
NPI:1619214079
Name:CAMPBELL, KELLY NICOLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NICOLE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:LEONARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24436 E LOUISIANA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80018
Mailing Address - Country:US
Mailing Address - Phone:443-783-7223
Mailing Address - Fax:
Practice Address - Street 1:26585 RALEIGH RD
Practice Address - Street 2:
Practice Address - City:MILLSBORO
Practice Address - State:DE
Practice Address - Zip Code:19966-7045
Practice Address - Country:US
Practice Address - Phone:443-783-7223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-05
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0013477225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant