Provider Demographics
NPI:1780072744
Name:CAMPBELL, STACI KATHERINE (RN)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:KATHERINE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 COLSON DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-4587
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 COLSON DR
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-4587
Practice Address - Country:US
Practice Address - Phone:850-558-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2022-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2034684164W00000X
KY1173119163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse