Provider Demographics
NPI:1619392529
Name:CAMPBELL, MARYUM
Entity Type:Individual
Prefix:
First Name:MARYUM
Middle Name:
Last Name:CAMPBELL
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 1:144 PROSPECT HILL RD
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-9618
Mailing Address - Country:US
Mailing Address - Phone:860-254-5694
Mailing Address - Fax:860-254-5694
Practice Address - Street 1:144 PROSPECT HILL RD
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-9618
Practice Address - Country:US
Practice Address - Phone:860-254-5694
Practice Address - Fax:860-254-5694
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTHCA0000676174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist