Provider Demographics
NPI:1285826065
Name:GLOVER-CAMPBELL, DIANA (CO, CPED, CFM)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GLOVER-CAMPBELL
Suffix:
Gender:F
Credentials:CO, CPED, CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 BROOKDALE DR
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4108
Mailing Address - Country:US
Mailing Address - Phone:704-872-1037
Mailing Address - Fax:704-872-1987
Practice Address - Street 1:520 BROOKDALE DR
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4108
Practice Address - Country:US
Practice Address - Phone:704-872-1037
Practice Address - Fax:704-872-1987
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECFM02153224900000X
DECPED0524224L00000X
MDC15207222Z00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795135Medicaid
NC7704084Medicaid
NC7795136Medicaid
NC7795450Medicaid
NC7795450Medicaid