Healthcare Provider Details

I. General information

NPI: 1629744677
Provider Name (Legal Business Name): BRANDON CAMPBELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 08/19/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 WOODED ACRE LN
LOUISVILLE KY
40245-2938
US

IV. Provider business mailing address

4121 WOODED ACRE LANE
LOUISVILLE KY
40245
US

V. Phone/Fax

Practice location:
  • Phone: 502-243-1643
  • Fax:
Mailing address:
  • Phone: 502-243-1643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SL0600X
TaxonomyLong-Term Care Clinical Nurse Specialist
License Number364SL0600X
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: