Basic Information
| Provider Information | |||||||||
| NPI: | 1598046559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | DEANN | ||||||||
| MiddleName: | SABRINA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACINNES | ||||||||
| OtherFirstName: | DEANN | ||||||||
| OtherMiddleName: | SABRINA | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3244 S KERCKHOFF AVE | ||||||||
| Address2: | |||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907316711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107491153 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1644 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MCKINLEYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955194342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078393068 | ||||||||
| FaxNumber: | 7078333827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2011 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | NP 20929 | CA | N | Nursing Service Providers | Registered Nurse | General Practice | 363L00000X | 20929 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.