Basic Information
| Provider Information | |||||||||
| NPI: | 1467895409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | BRYNNE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 WELLSTAR WAY STE 105 | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301148952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784942500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1120 WELLSTAR WAY STE 105 | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301148952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784942500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2013 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9107144 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 7442 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | HE879Z | 01 | FL | PTAN | OTHER |