Healthcare Provider Details

I. General information

NPI: 1629714928
Provider Name (Legal Business Name): JESSICA R CAMPBELL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

4340 SAN MATEO BLVD NE
ALBUQUERQUE NM
87110-1234
US

IV. Provider business mailing address

4340 SAN MATEO BLVD NE
ALBUQUERQUE NM
87110-1234
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-0417
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number62038
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: