Healthcare Provider Details

I. General information

NPI: 1720621279
Provider Name (Legal Business Name): RACHEL CLAIRE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RACHEL CLAIRE WALTZ RN

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5716 MICHIGAN AVE
DETROIT MI
48210-3039
US

IV. Provider business mailing address

559 W GRAND BLVD
DETROIT MI
48216-2200
US

V. Phone/Fax

Practice location:
  • Phone: 313-554-1095
  • Fax: 313-899-3560
Mailing address:
  • Phone: 313-554-0485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704295523
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4704295523
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: