Provider Demographics
NPI:1063906923
Name:CAMPBELL, KYLEEN ALANE (LMP)
Entity type:Individual
Prefix:
First Name:KYLEEN
Middle Name:ALANE
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 1:2414 NW MYHRE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7669
Mailing Address - Country:US
Mailing Address - Phone:360-692-2273
Mailing Address - Fax:360-307-7256
Practice Address - Street 1:2414 NW MYHRE RD STE 120
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7669
Practice Address - Country:US
Practice Address - Phone:360-692-2273
Practice Address - Fax:360-307-7256
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60815444225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60815444OtherLMP