Provider Demographics
NPI:1316226285
Name:CAMPBELL, THERESA LYNNE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNNE
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 1:401 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43732-9770
Mailing Address - Country:US
Mailing Address - Phone:740-882-4001
Mailing Address - Fax:
Practice Address - Street 1:401 MAPLE ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:OH
Practice Address - Zip Code:43732-9770
Practice Address - Country:US
Practice Address - Phone:740-882-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3138214Medicaid