Provider Demographics
NPI:1710192687
Name:CAMPBELL, CHRISTY GRACE (LMP)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:GRACE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8903 KEY PENINSULA HWY N
Mailing Address - Street 2:
Mailing Address - City:LAKEBAY
Mailing Address - State:WA
Mailing Address - Zip Code:98349-9326
Mailing Address - Country:US
Mailing Address - Phone:253-820-8060
Mailing Address - Fax:253-884-2632
Practice Address - Street 1:5110 LACKEY ROAD KP N
Practice Address - Street 2:
Practice Address - City:VAUGHN
Practice Address - State:WA
Practice Address - Zip Code:98394-9663
Practice Address - Country:US
Practice Address - Phone:253-884-2144
Practice Address - Fax:253-884-5293
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013232171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1047CAOtherREGENCEBLUESHIELD
WA0131876OtherLABOR AND INDUSTRIES