Provider Demographics
NPI:1184163107
Name:CAMPBELL, DEIDRA (RD)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:DEIDRA
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:412 SURI DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-4374
Mailing Address - Country:US
Mailing Address - Phone:901-210-6750
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-2127
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002908133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered