Basic Information
| Provider Information | |||||||||
| NPI: | 1720621279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | CLAIRE | ||||||||
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| OtherLastName: | WALTZ | ||||||||
| OtherFirstName: | RACHEL | ||||||||
| OtherMiddleName: | CLAIRE | ||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 559 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482162200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135540485 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5716 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482103039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135541095 | ||||||||
| FaxNumber: | 3138993560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2019 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 4704295523 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LW0102X | 4704295523 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.