Provider Demographics
NPI:1265583389
Name:CAMPBELL, IRENE GANSSLE (NP)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:GANSSLE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-2414
Mailing Address - Country:US
Mailing Address - Phone:781-330-9763
Mailing Address - Fax:
Practice Address - Street 1:950 WINTER ST
Practice Address - Street 2:SUITE 3800
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1424
Practice Address - Country:US
Practice Address - Phone:781-472-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA119131NP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology