Provider Demographics
NPI:1164056495
Name:CAMPBELL, MOLLY KATE
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:KATE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N OAK AVE STE D
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2435
Mailing Address - Country:US
Mailing Address - Phone:931-783-5582
Mailing Address - Fax:
Practice Address - Street 1:406 N WHITNEY AVE STE 5
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4243
Practice Address - Country:US
Practice Address - Phone:931-783-4269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant