Provider Demographics
NPI:1023352465
Name:CAMPBELL, CODY S (CRNA)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:S
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 PARK ST
Mailing Address - Street 2:SUITE 203B
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1784
Mailing Address - Country:US
Mailing Address - Phone:270-393-1912
Mailing Address - Fax:270-393-1913
Practice Address - Street 1:350 PARK ST
Practice Address - Street 2:SUITE 203B
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1784
Practice Address - Country:US
Practice Address - Phone:270-393-1912
Practice Address - Fax:270-393-1913
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN90844367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered