Basic Information
Provider Information | |||||||||
NPI: | 1144744517 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAMPBELL | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 350 NEW FIDELITY CT | ||||||||
Address2: |   | ||||||||
City: | GARNER | ||||||||
State: | NC | ||||||||
PostalCode: | 275292665 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9192582714 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3801 WAKE FOREST RD STE 230 | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276096864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9193220042 | ||||||||
FaxNumber: | 9193220041 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2017 | ||||||||
LastUpdateDate: | 11/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | P17313 | NC | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | P17313 | NC | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | P17313 | 01 | NC | NCBPT | OTHER |