Provider Demographics
NPI:1114109808
Name:CAMPBELL, MARY E (APRN, BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 OGUNQUIT RD
Mailing Address - Street 2:
Mailing Address - City:CAPE NEDDICK
Mailing Address - State:ME
Mailing Address - Zip Code:03902-7938
Mailing Address - Country:US
Mailing Address - Phone:207-361-1593
Mailing Address - Fax:
Practice Address - Street 1:789 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2526
Practice Address - Country:US
Practice Address - Phone:603-742-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA164940363LA2100X
NH067174-23363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3100171Medicaid