Basic Information
| Provider Information | |||||||||
| NPI: | 1821500554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | AMBER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6891 SE 103RD PL | ||||||||
| Address2: | |||||||||
| City: | BELLEVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344209324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525046881 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347482841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523143760 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2017 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 106E00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 023021000 | 05 | FL | MEDICAID |