Provider Demographics
NPI:1831558584
Name:CAMPBELL, LESLIE A (MT)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
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:PO BOX 74612
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-4612
Mailing Address - Country:US
Mailing Address - Phone:907-347-2934
Mailing Address - Fax:907-459-8201
Practice Address - Street 1:725 2ND AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4450
Practice Address - Country:US
Practice Address - Phone:907-347-2934
Practice Address - Fax:907-459-8201
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101554225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK101554OtherSTATE OF ALASKA