Provider Demographics
NPI:1992241830
Name:CAMPBELL, MAXINE HELEN
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:HELEN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5971 SUITE C NEW JESUP HWY
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-1627
Mailing Address - Country:US
Mailing Address - Phone:912-242-1130
Mailing Address - Fax:912-342-8177
Practice Address - Street 1:5971 SUITE C NEW JESUP HWY
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-1627
Practice Address - Country:US
Practice Address - Phone:912-242-1130
Practice Address - Fax:912-342-8177
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063-R-1722163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1811371065OtherHHA