Healthcare Provider Details

I. General information

NPI: 1588012819
Provider Name (Legal Business Name): DANIELLE NICOLE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date: 04/18/2022
Reactivation Date: 05/17/2022

III. Provider practice location address

120 STEVENS ST SW
GRAND RAPIDS MI
49507-1526
US

IV. Provider business mailing address

7108 SOUTH KANNER HWY
STUART FL
34997-7462
US

V. Phone/Fax

Practice location:
  • Phone: 517-586-4121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: