Provider Demographics
NPI:1295227106
Name:CAMPBELL, CARIANNE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CARIANNE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 SEVERN AVE
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-3934
Mailing Address - Country:US
Mailing Address - Phone:240-304-8574
Mailing Address - Fax:
Practice Address - Street 1:2000 MEDICAL PKWY STE 404
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3746
Practice Address - Country:US
Practice Address - Phone:443-481-1140
Practice Address - Fax:443-481-1148
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
MDA3674225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant