Provider Demographics
NPI:1184104689
Name:CAMPBELL, INDRA
Entity type:Individual
Prefix:
First Name:INDRA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 PINES BLVD STE 415-409
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6455
Mailing Address - Country:US
Mailing Address - Phone:954-272-6103
Mailing Address - Fax:954-637-1888
Practice Address - Street 1:9050 PINES BLVD STE 415-409
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6455
Practice Address - Country:US
Practice Address - Phone:954-272-6103
Practice Address - Fax:954-637-1888
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101133500Medicaid