Healthcare Provider Details

I. General information

NPI: 1083348916
Provider Name (Legal Business Name): SARAH E CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 10/15/2022
Certification Date: 10/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CHARLTON RD
BALLSTON LAKE NY
12019-2547
US

IV. Provider business mailing address

112 CHARLTON RD
BALLSTON LAKE NY
12019-2547
US

V. Phone/Fax

Practice location:
  • Phone: 518-399-7723
  • Fax:
Mailing address:
  • Phone: 518-399-7723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number645103
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number350018
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: