Healthcare Provider Details

I. General information

NPI: 1962024109
Provider Name (Legal Business Name): BRITTANY NICOLE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 08/17/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2266 BOYSENBERRY LN APT 4
SPRINGFIELD IL
62711-5414
US

IV. Provider business mailing address

2266 BOYSENBERRY LN APT 4
SPRINGFIELD IL
62711-5414
US

V. Phone/Fax

Practice location:
  • Phone: 618-964-4905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.008537
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: