Basic Information
| Provider Information | |||||||||
| NPI: | 1992257232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 W NC HIGHWAY 54 STE 103 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277075572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193540840 | ||||||||
| FaxNumber: | 9197484441 | ||||||||
| Practice Location | |||||||||
| Address1: | 3610 BUSH ST | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198763130 | ||||||||
| FaxNumber: | 9198763134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2016 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 6786 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP2300X | 6786 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP0808X | 2010155 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 008069118 | 01 | CT | CAMPBELL MEDICAID # | OTHER |