Provider Demographics
NPI:1477100519
Name:CAMPBELL, KIRSTEN RASHAE (NP)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:RASHAE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:RASHAE
Other - Last Name:VITOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-948-8016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28236336A163W00000X
IN71011020A363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300050076Medicaid
IN090540692OtherMEDICARE PTAN