Provider Demographics
NPI:1609932821
Name:CAMPBELL, CYNTHIA SUE (MASTER OF SCIENCE)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:SUE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MASTER OF SCIENCE
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:SUE
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:38135 MARKET SQ
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-7505
Practice Address - Country:US
Practice Address - Phone:813-778-0444
Practice Address - Fax:813-355-5017
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1330542363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01624067OtherRR MEDICARE
FL016874100Medicaid
FLIM670Z - PASCOMedicare PIN
FL016874100Medicaid
FLIM670Y- HILLSBOROUGHMedicare PIN
FL41-1289245OtherFEDERAL TAX ID #