Basic Information
| Provider Information | |||||||||
| NPI: | 1972531259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, CNM, ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2215 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402121033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027748631 | ||||||||
| FaxNumber: | 5027783499 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402121033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027748631 | ||||||||
| FaxNumber: | 5027783499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 10/25/2012 | ||||||||
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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 | 363LW0102X | 812P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 78000213 | 05 | KY | MEDICAID |