Healthcare Provider Details

I. General information

NPI: 1326467374
Provider Name (Legal Business Name): BEVERLY CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 S 10TH ST
FORT PIERCE FL
34982-4306
US

IV. Provider business mailing address

2808 S 10TH ST
FORT PIERCE FL
34982-4306
US

V. Phone/Fax

Practice location:
  • Phone: 772-672-1555
  • Fax:
Mailing address:
  • Phone: 772-672-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number6906322
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: