Provider Demographics
NPI:1316168586
Name:CAMPBELL, KENNETH (NP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42084 STATE HIGHWAY 28
Mailing Address - Street 2:
Mailing Address - City:MARGARETVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12455
Mailing Address - Country:US
Mailing Address - Phone:845-586-2631
Mailing Address - Fax:
Practice Address - Street 1:42084 STATE HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:MARGARETVILLE
Practice Address - State:NY
Practice Address - Zip Code:12455
Practice Address - Country:US
Practice Address - Phone:845-586-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330869363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP41400Medicare ID - Type Unspecified