Provider Demographics
NPI:1841772563
Name:CAMPO, LOURDES PATRICIA SR
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:PATRICIA
Last Name:CAMPO
Suffix:SR
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 1:1348 WESTWINDS DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-3846
Mailing Address - Country:US
Mailing Address - Phone:321-274-2033
Mailing Address - Fax:
Practice Address - Street 1:1348 WESTWINDS DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-3846
Practice Address - Country:US
Practice Address - Phone:321-274-2033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC516535919710172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver