Provider Demographics
NPI:1225426299
Name:CAMPBELL, KEVIN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:FNP-BC
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:304 MOUNT MERCY DR
Practice Address - Street 2:
Practice Address - City:PEWEE VALLEY
Practice Address - State:KY
Practice Address - Zip Code:40056-8020
Practice Address - Country:US
Practice Address - Phone:502-241-8611
Practice Address - Fax:502-241-4175
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009043363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50083157OtherPASSPORT
KY7100326440Medicaid
KY7100326440Medicaid