Basic Information
| Provider Information | |||||||||
| NPI: | 1124355144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | BLAIR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1019 PACIFIC AVE | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984024443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537221540 | ||||||||
| FaxNumber: | 2535974556 | ||||||||
| Practice Location | |||||||||
| Address1: | 10510 GRAVELLY LAKE DR SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984995036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535897030 | ||||||||
| FaxNumber: | 2535897033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2009 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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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 | 207Q00000X | MD60463468 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD9572 | 05 | AK | MEDICAID |