Provider Demographics
NPI:1053474262
Name:CAMPBELL, ELOISE (NP,CDE,BC-ADM)
Entity Type:Individual
Prefix:
First Name:ELOISE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:NP,CDE,BC-ADM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 BREAUX DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 DUPONT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4692
Practice Address - Country:US
Practice Address - Phone:502-895-2334
Practice Address - Fax:502-896-6987
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003087363LA2200X
IN71001251A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3003087OtherSTATE LICENSE
IN71001251AOtherSTATE LICENSE