Provider Demographics
NPI:1154651925
Name:CAMPBELL, NICOLE M (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69355
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058
Practice Address - Country:US
Practice Address - Phone:541-296-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-30
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201500184CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNR14585000OtherSTATE LICENSE
OR201500184CRNAOtherSTATE
NJ171441AUAMedicare PIN