Provider Demographics
NPI:1346321577
Name:CAMPBELL, MARY SUSAN (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:PIRTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 SW COAST HWY
Mailing Address - Street 2:STE 203
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-5215
Mailing Address - Country:US
Mailing Address - Phone:573-210-1010
Mailing Address - Fax:
Practice Address - Street 1:1010 SW COAST HWY
Practice Address - Street 2:SUITE 203
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-5288
Practice Address - Country:US
Practice Address - Phone:541-265-4947
Practice Address - Fax:541-574-7670
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137448363LF0000X
IL209015842363L00000X
OR201600925NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1346321577Medicaid
MO428755920Medicaid
MOQ08552Medicare UPIN
MO1346321577Medicaid
ORR189948Medicare PIN