Provider Demographics
NPI:1104452051
Name:CAMPBELL, NICOLE LAVON-RENEE (CNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LAVON-RENEE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6632 OH-48
Mailing Address - Street 2:
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:
Practice Address - Street 1:6632 S STATE ROUTE 48
Practice Address - Street 2:
Practice Address - City:MAINEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45039-9758
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH026298363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408847Medicaid