Provider Demographics
NPI:1639643554
Name:CAMPBELL, KALISSA MARIE
Entity Type:Individual
Prefix:
First Name:KALISSA
Middle Name:MARIE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KALISSA
Other - Middle Name:MARIE
Other - Last Name:BANDINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1175 PARK PL APT 229
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1584
Mailing Address - Country:US
Mailing Address - Phone:775-233-7019
Mailing Address - Fax:
Practice Address - Street 1:931 SAN BRUNO AVE W RM 2
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3435
Practice Address - Country:US
Practice Address - Phone:415-681-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker