Healthcare Provider Details

I. General information

NPI: 1326867508
Provider Name (Legal Business Name): BRYCE CAMPBELL CHILD FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 E SOUTHERN AVE
MESA AZ
85204-5411
US

IV. Provider business mailing address

10200 GRAND CENTRAL AVE STE 220
OWINGS MILLS MD
21117-4366
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-4188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10634634-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number317451
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: