Provider Demographics
NPI:1134908379
Name:CAMPBELL, MICHELLE LYNN (LAC)
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:LYNN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7705 N PENINSULAR AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-6240
Mailing Address - Country:US
Mailing Address - Phone:860-861-4091
Mailing Address - Fax:
Practice Address - Street 1:1427 NW FLANDERS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2646
Practice Address - Country:US
Practice Address - Phone:503-972-0235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR214034171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist