Provider Demographics
NPI:1871840470
Name:CAMPAGNA, NIKKI E (AA-C)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:E
Last Name:CAMPAGNA
Suffix:
Gender:F
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 VALENCIA ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-3566
Mailing Address - Country:US
Mailing Address - Phone:407-451-3886
Mailing Address - Fax:
Practice Address - Street 1:1912 SE 1ST TER
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990
Practice Address - Country:US
Practice Address - Phone:407-451-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA216367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1871840470Medicaid