Provider Demographics
NPI:1063103646
Name:CAMPBELL, MARQUESA RAE (PMHNP)
Entity type:Individual
Prefix:
First Name:MARQUESA
Middle Name:RAE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10290 N NORTH COUNTY BLVD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-6012
Mailing Address - Country:US
Mailing Address - Phone:435-776-5909
Mailing Address - Fax:
Practice Address - Street 1:10290 N NORTH COUNTY BLVD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-8973
Practice Address - Country:US
Practice Address - Phone:435-776-5909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2022151948363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health