Provider Demographics
NPI:1942402532
Name:CAMPBELL, MARY JANE (CPNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12655 N CENTRAL EXPY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-1700
Mailing Address - Country:US
Mailing Address - Phone:972-788-1858
Mailing Address - Fax:972-788-2798
Practice Address - Street 1:12655 N CENTRAL EXPY
Practice Address - Street 2:SUITE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1700
Practice Address - Country:US
Practice Address - Phone:972-788-1858
Practice Address - Fax:972-788-2798
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX501269363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX62628502Medicaid