Provider Demographics
NPI:1952344020
Name:CAMPBELL, SHERESA KETRON (APRN)
Entity type:Individual
Prefix:
First Name:SHERESA
Middle Name:KETRON
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9890
Mailing Address - Fax:239-343-9898
Practice Address - Street 1:15901 BASS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-343-9890
Practice Address - Fax:239-343-9898
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1411892364SN0000X, 363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307034400Medicaid