Healthcare Provider Details

I. General information

NPI: 1396855409
Provider Name (Legal Business Name): HENRY GRADY CAMPBELL JR R.N. C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

864 RIMROCK DR
GALLUP NM
87301-7347
US

V. Phone/Fax

Practice location:
  • Phone: 800-465-8262
  • Fax:
Mailing address:
  • Phone: 505-863-5071
  • Fax: 505-722-0723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberR 0024189
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number12898
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: