Provider Demographics
NPI:1558044842
Name:CAMPOS, NELLYANN
Entity Type:Individual
Prefix:
First Name:NELLYANN
Middle Name:
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 NW 112TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33167-3622
Mailing Address - Country:US
Mailing Address - Phone:786-623-1938
Mailing Address - Fax:
Practice Address - Street 1:1610 NW 112TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33167-3622
Practice Address - Country:US
Practice Address - Phone:786-623-1938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician