Healthcare Provider Details

I. General information

NPI: 1083675615
Provider Name (Legal Business Name): NIOAKA NICOLE CAMPBELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MEDICAL PARK RD SUITE 103
COLUMBIA SC
29203-8003
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-4300
  • Fax: 803-434-4351
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number22533
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: