Provider Demographics
NPI:1891732103
Name:HARRIS-CAMPBELL, SUPORIOR R (DNP)
Entity Type:Individual
Prefix:MRS
First Name:SUPORIOR
Middle Name:R
Last Name:HARRIS-CAMPBELL
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:MRS
Other - First Name:SUPORIOR
Other - Middle Name:R
Other - Last Name:HARRIS
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:DNP
Mailing Address - Street 1:12125 WOODCREST EXECUTIVE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5001
Mailing Address - Country:US
Mailing Address - Phone:314-317-0600
Mailing Address - Fax:314-317-0606
Practice Address - Street 1:5 MOBILE INFIRMARY CIR
Practice Address - Street 2:POB SUITE 308
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3513
Practice Address - Country:US
Practice Address - Phone:251-435-7223
Practice Address - Fax:251-435-7282
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1063773363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL133128Medicaid
AL133128Medicaid