Provider Demographics
NPI:1962954016
Name:CAMPBELL, VICKEY (RN)
Entity type:Individual
Prefix:
First Name:VICKEY
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4083 STONEBRIDGE
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-9529
Mailing Address - Country:US
Mailing Address - Phone:248-421-0889
Mailing Address - Fax:
Practice Address - Street 1:4083 STONEBRIDGE
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-9529
Practice Address - Country:US
Practice Address - Phone:248-421-0889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47042519801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704251980Medicaid