Provider Demographics
NPI:1962592220
Name:CAMPBELL, SHELLEY JEAN (CNNP)
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:JEAN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 ARGUS STREET
Mailing Address - Street 2:
Mailing Address - City:LASALLE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9J 3G5
Mailing Address - Country:CA
Mailing Address - Phone:519-734-7590
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-0467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704182158363LN0000X, 363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ24657036Medicare PIN