Healthcare Provider Details

I. General information

NPI: 1871004358
Provider Name (Legal Business Name): SHANNON LEE CAMPBELL AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 ARCHER ST
CLYDE TX
79510-4225
US

IV. Provider business mailing address

102 ARCHER ST
CLYDE TX
79510-4225
US

V. Phone/Fax

Practice location:
  • Phone: 325-893-1010
  • Fax: 325-893-1442
Mailing address:
  • Phone: 325-893-1010
  • Fax: 325-893-1442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP135592
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: