Provider Demographics
NPI:1063413029
Name:CAMPBELL, SUSAN L (CNM)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:L
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-589-3100
Mailing Address - Fax:740-589-3123
Practice Address - Street 1:2131 EAST STATE ST.
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:740-589-3100
Practice Address - Fax:740-589-3123
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNM.10196367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000259823OtherOH MEDICAID UNISON
OH2882288OtherOH MEDICAID MOLINA
OH2882288Medicaid
P00665594OtherRAILROAD MEDICARE
OH310917085201OtherOH MEDICAID CARESOURCE
WV3810013422Medicaid
WV3810013422Medicaid
OH2882288Medicaid