Basic Information
| Provider Information | |||||||||
| NPI: | 1922036185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72 E MCNAB RD | ||||||||
| Address2: | |||||||||
| City: | POMPANO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330609238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545450337 | ||||||||
| FaxNumber: | 9545453497 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 RIVERVIEW ST | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287342612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283694231 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 124392 | NC | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 8050184 | 05 | NC | MEDICAID | P00261910 | 01 | NC | RAILROAD MEDICARE | OTHER |