Provider Demographics
NPI:1629102025
Name:CAMPBELL, THERESA ANN (APRN,BC,FNP)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:APRN,BC,FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 WEST FRONT STREET
Mailing Address - Street 2:
Mailing Address - City:SLATER
Mailing Address - State:MO
Mailing Address - Zip Code:65349-1328
Mailing Address - Country:US
Mailing Address - Phone:660-529-2251
Mailing Address - Fax:660-831-3348
Practice Address - Street 1:420 WEST FRONT STREET
Practice Address - Street 2:
Practice Address - City:SLATER
Practice Address - State:MO
Practice Address - Zip Code:65349-1328
Practice Address - Country:US
Practice Address - Phone:660-529-2251
Practice Address - Fax:660-831-3348
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN069859363LF0000X
MO069859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1629102025Medicaid
MOP14445Medicare UPIN