Provider Demographics
NPI:1275813719
Name:CAMPBELL-WIGINGTON, KELLY ELIZABETH (PMHNP, FNP-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:CAMPBELL-WIGINGTON
Suffix:
Gender:F
Credentials:PMHNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7890 LAKE SAWGRASS LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-6640
Mailing Address - Country:US
Mailing Address - Phone:239-560-2179
Mailing Address - Fax:
Practice Address - Street 1:12590 WHITEHALL DR STE 3
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4680
Practice Address - Country:US
Practice Address - Phone:239-939-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN3076452363LP0808X
FL3076452363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily