Basic Information
| Provider Information | |||||||||
| NPI: | 1891247441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENNINGS | ||||||||
| OtherFirstName: | AMBER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 700 N COLUMBUS ST | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448271455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195296195 | ||||||||
| FaxNumber: | 4195299187 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 RICHLAND MALL | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449063802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195296195 | ||||||||
| FaxNumber: | 4195299187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2016 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.019967 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0149428 | 05 | OH | MEDICAID |