Healthcare Provider Details

I. General information

NPI: 1679839971
Provider Name (Legal Business Name): MANDY NICOLE CAMPBELL P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 TUSCULUM BLVD.
GREENEVILLE TN
37745
US

IV. Provider business mailing address

1420 TUSCULUM BLVD.
GREENEVILLE TN
37745
US

V. Phone/Fax

Practice location:
  • Phone: 423-787-5063
  • Fax: 423-787-5017
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3634
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: