Basic Information
| Provider Information | |||||||||
| NPI: | 1639643554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | KALISSA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BANDINI | ||||||||
| OtherFirstName: | KALISSA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1175 PARK PL APT 229 | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944031584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752337019 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 931 SAN BRUNO AVE W RM 2 | ||||||||
| Address2: | |||||||||
| City: | SAN BRUNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940663435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156813211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2019 | ||||||||
| LastUpdateDate: | 01/14/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | CA | Y | Other Service Providers | Community Health Worker |
No ID Information.