Provider Demographics
NPI:1659409365
Name:CAMPBELL, KENNETH WAYNE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:PROF
Other - First Name:KENNETH
Other - Middle Name:WAYNE
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:727 COUNTY ROAD 8
Mailing Address - Street 2:
Mailing Address - City:HEFLIN
Mailing Address - State:AL
Mailing Address - Zip Code:36264-3651
Mailing Address - Country:US
Mailing Address - Phone:256-253-2885
Mailing Address - Fax:
Practice Address - Street 1:1701 PELHAM ROAD
Practice Address - Street 2:JACKSONVILLE MEDICAL CENTER
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265
Practice Address - Country:US
Practice Address - Phone:256-435-4970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26081367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered