1710192687 NPI number — CHRISTY GRACE CAMPBELL LMP

Table of content: CHRISTY GRACE CAMPBELL LMP (NPI 1710192687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710192687 NPI number — CHRISTY GRACE CAMPBELL LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMPBELL
Provider First Name:
CHRISTY
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710192687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8903 KEY PENINSULA HWY N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEBAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98349-9326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-820-8060
Provider Business Mailing Address Fax Number:
253-884-2632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5110 LACKEY ROAD KP N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VAUGHN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98394-9663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-884-2144
Provider Business Practice Location Address Fax Number:
253-884-5293
Provider Enumeration Date:
05/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  MA00013232 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1047CA . This is a "REGENCEBLUESHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0131876 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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