Provider Demographics
NPI:1467513085
Name:CAMPBELL, LYDIA JO (APRN)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:JO
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:KESSLUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14746 NAIMISHA LOOP
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-0778
Mailing Address - Country:US
Mailing Address - Phone:864-488-6811
Mailing Address - Fax:
Practice Address - Street 1:15205 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6072
Practice Address - Country:US
Practice Address - Phone:352-597-7744
Practice Address - Fax:352-597-7797
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9302121367500000X
SC1443367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001884300Medicaid
SCNAN 143Medicaid