Provider Demographics
NPI:1518377290
Name:CAMPBELL, BRWYAN (MA, ATC)
Entity Type:Individual
Prefix:
First Name:BRWYAN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 BRANNER AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-2210
Mailing Address - Country:US
Mailing Address - Phone:865-471-3419
Mailing Address - Fax:
Practice Address - Street 1:2130 BRANNER AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2210
Practice Address - Country:US
Practice Address - Phone:865-471-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000014512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer