Provider Demographics
NPI:1962515908
Name:CAMPBELL, LYNN B (RD, CDE)
Entity type:Individual
Prefix:MS
First Name:LYNN
Middle Name:B
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1900
Mailing Address - Fax:
Practice Address - Street 1:111 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4317
Practice Address - Country:US
Practice Address - Phone:704-874-3300
Practice Address - Fax:704-874-0065
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYL000681133V00000X
NCL000681133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ356929246Medicare PIN
NCQ30852Medicare UPIN
NC2993962AMedicare PIN