Provider Demographics
NPI:1639696867
Name:CAMPBELL, KELLY L (NP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:LAKIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:230 CLEARFIELD AVE STE 124
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3383
Mailing Address - Fax:
Practice Address - Street 1:1800 CAMELOT DR STE 300
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2440
Practice Address - Country:US
Practice Address - Phone:757-321-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA95065961163W00000X
VA0024175463363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse