Provider Demographics
NPI:1821727876
Name:CAMPBELL, KATTYA
Entity Type:Individual
Prefix:
First Name:KATTYA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 MYERS ST. ENTRANCE 3, OFFICE # 243
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5527
Mailing Address - Country:US
Mailing Address - Phone:951-358-7630
Mailing Address - Fax:
Practice Address - Street 1:3125 MYERS ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5527
Practice Address - Country:US
Practice Address - Phone:951-358-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-WVMHZQ175T00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA175T00000XMedicaid
CA172V00000XMedicaid