Healthcare Provider Details

I. General information

NPI: 1750728085
Provider Name (Legal Business Name): AMY CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 34 BOX 34165
ELY NV
89301-9206
US

IV. Provider business mailing address

HC 34 BOX 34165
ELY NV
89301-9206
US

V. Phone/Fax

Practice location:
  • Phone: 775-238-5100
  • Fax: 775-238-5103
Mailing address:
  • Phone: 775-238-5100
  • Fax: 775-238-5103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: