Provider Demographics
NPI:1679699458
Name:CAMPBELL, MILTIA ALEXA MARIE III
Entity Type:Individual
Prefix:MRS
First Name:MILTIA
Middle Name:ALEXA MARIE
Last Name:CAMPBELL
Suffix:III
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 1:1505 JOHN BEVY CT
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086-1382
Mailing Address - Country:US
Mailing Address - Phone:330-389-1250
Mailing Address - Fax:
Practice Address - Street 1:1505 JOHN BEVY CT
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-1382
Practice Address - Country:US
Practice Address - Phone:330-389-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6701877374U00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1396950374Medicaid
OH2657478Medicaid