Healthcare Provider Details

I. General information

NPI: 1740108844
Provider Name (Legal Business Name): IESHA LANAE CAMPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 COLLEGE MAIN ST APT 36
BRYAN TX
77801
US

IV. Provider business mailing address

4110 COLLEGE MAIN ST APT 36
BRYAN TX
77801
US

V. Phone/Fax

Practice location:
  • Phone: 979-422-6938
  • Fax:
Mailing address:
  • Phone: 979-422-6938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number50917700
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: