Provider Demographics
NPI:1396401337
Name:CAMPBELL, NICOLE LEE (LPN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BUNTLINE DR
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12167-1203
Mailing Address - Country:US
Mailing Address - Phone:607-652-2960
Mailing Address - Fax:607-652-7901
Practice Address - Street 1:1 BUNTLINE DR
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:NY
Practice Address - Zip Code:12167-1203
Practice Address - Country:US
Practice Address - Phone:607-658-2960
Practice Address - Fax:607-652-7901
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323349164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty