Provider Demographics
NPI:1245347657
Name:CAMPBELL, IDA LOUISE (FNP)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:LOUISE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:CAMPBELL
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:502 54TH AVE E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-2724
Mailing Address - Country:US
Mailing Address - Phone:253-459-7500
Mailing Address - Fax:253-459-7527
Practice Address - Street 1:502 54TH AVE E
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-2724
Practice Address - Country:US
Practice Address - Phone:253-459-7500
Practice Address - Fax:253-459-7527
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003481363LF0000X
OR200650038NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily