Provider Demographics
NPI:1962419481
Name:KIM-CAMPO, KELLY B (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:KIM-CAMPO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:B
Other - Last Name:CAMPO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:563 MADISON AVE N
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1768
Mailing Address - Country:US
Mailing Address - Phone:206-855-8455
Mailing Address - Fax:206-855-8465
Practice Address - Street 1:563 MADISON AVE N
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1768
Practice Address - Country:US
Practice Address - Phone:206-855-8455
Practice Address - Fax:206-855-8465
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPI00006092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB33179Medicare UPIN