Provider Demographics
NPI:1962004515
Name:CAMPBELL, MISTY (LPN)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5154 BROWN LEAF WAY
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-8910
Mailing Address - Country:US
Mailing Address - Phone:678-779-0431
Mailing Address - Fax:
Practice Address - Street 1:5154 BROWN LEAF WAY
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-8910
Practice Address - Country:US
Practice Address - Phone:678-779-0431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN078372164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse