Healthcare Provider Details

I. General information

NPI: 1417445933
Provider Name (Legal Business Name): DEANNA ROSHELLE CAMPBELL SANDBURG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 AMERICAN GREETING CARD RD
CORBIN KY
40701-4811
US

IV. Provider business mailing address

142 PRINCE LN
BAXTER KY
40806-8593
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-7010
  • Fax:
Mailing address:
  • Phone: 423-248-9967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: