Provider Demographics
NPI:1093729170
Name:CAMPBELL, COLLETT (CPED, LPED)
Entity Type:Individual
Prefix:MRS
First Name:COLLETT
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CPED, LPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4668
Mailing Address - Country:US
Mailing Address - Phone:405-707-3005
Mailing Address - Fax:405-707-3033
Practice Address - Street 1:724 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4668
Practice Address - Country:US
Practice Address - Phone:405-707-3005
Practice Address - Fax:405-707-3033
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK80174400000X, 224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK6754740001Medicare NSC