Provider Demographics
NPI:1548279037
Name:CAMPBELL, CORA MICHELLE (CRNA)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:MICHELLE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 CHESTNUT RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:KENNA
Mailing Address - State:WV
Mailing Address - Zip Code:25248
Mailing Address - Country:US
Mailing Address - Phone:304-372-2341
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVENUE, SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-5559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV44162163W00000X
WV073556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005178Medicaid