Provider Demographics
NPI:1699036178
Name:CAMPBELL, VICTORIA LYNN (RDN)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:TEMPLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:117 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-6610
Mailing Address - Country:US
Mailing Address - Phone:662-212-2219
Mailing Address - Fax:
Practice Address - Street 1:117 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-6610
Practice Address - Country:US
Practice Address - Phone:662-212-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82188133VN1004X
MSD1688133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX149984001Medicaid
TX456606Medicare PIN