Provider Demographics
NPI:1063524114
Name:CAMPBELL, SUSAN DIANE (APRN,BS)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DIANE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:APRN,BS
Other - Prefix:
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Mailing Address - Street 1:9104 ROARING SPRING LOOP
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-2109
Mailing Address - Country:US
Mailing Address - Phone:703-392-1078
Mailing Address - Fax:703-289-2764
Practice Address - Street 1:3340 WOODBURN RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1202
Practice Address - Country:US
Practice Address - Phone:703-289-2781
Practice Address - Fax:703-289-2764
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000809364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult