Provider Demographics
NPI:1396550661
Name:CAMPBELL, ANDREA (LMT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 N OLD HIGHWAY 91
Mailing Address - Street 2:
Mailing Address - City:INKOM
Mailing Address - State:ID
Mailing Address - Zip Code:83245-1724
Mailing Address - Country:US
Mailing Address - Phone:801-671-6074
Mailing Address - Fax:
Practice Address - Street 1:514 N OLD HIGHWAY 91
Practice Address - Street 2:
Practice Address - City:INKOM
Practice Address - State:ID
Practice Address - Zip Code:83245-1724
Practice Address - Country:US
Practice Address - Phone:801-671-6074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6271446225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist