Provider Demographics
NPI:1396855409
Name:CAMPBELL JR, HENRY GRADY (RN C)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:GRADY
Last Name:CAMPBELL JR
Suffix:
Gender:M
Credentials:RN C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:864 RIMROCK DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-7347
Mailing Address - Country:US
Mailing Address - Phone:505-863-5071
Mailing Address - Fax:505-722-0723
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:800-465-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR 0024189163WA0400X
AK12898163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)