Provider Demographics
NPI:1679225213
Name:CAMPBELL, KIMBERLY (MT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 HIGHPOINT WAY
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-6504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:779 HIGHPOINT WAY
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-6504
Practice Address - Country:US
Practice Address - Phone:619-209-0934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55376225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist