Healthcare Provider Details

I. General information

NPI: 1013771393
Provider Name (Legal Business Name): SHANNA LEE CAMPBELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 02/07/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42121 US HIGHWAY 70
PORTALES NM
88130-9054
US

IV. Provider business mailing address

42121 US HIGHWAY 70
PORTALES NM
88130-9054
US

V. Phone/Fax

Practice location:
  • Phone: 575-356-6652
  • Fax:
Mailing address:
  • Phone: 575-356-6652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77810
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: