Provider Demographics
NPI:1154954576
Name:CAMPBELL, SHAWNA KIMBERLY
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:KIMBERLY
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 1:1066 GARDENA RD
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-4604
Mailing Address - Country:US
Mailing Address - Phone:760-402-7966
Mailing Address - Fax:
Practice Address - Street 1:619 S VULCAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-3653
Practice Address - Country:US
Practice Address - Phone:760-402-7966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9489174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist