Provider Demographics
NPI:1750022679
Name:CAMPO, GINA NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:NICOLE
Last Name:CAMPO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11831 PEARL RD APT 308
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-3337
Mailing Address - Country:US
Mailing Address - Phone:440-724-2045
Mailing Address - Fax:
Practice Address - Street 1:6765 STATE RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-4581
Practice Address - Country:US
Practice Address - Phone:440-843-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA013068225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant