Healthcare Provider Details

I. General information

NPI: 1063524114
Provider Name (Legal Business Name): SUSAN DIANE CAMPBELL APRN,BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 WOODBURN RD
ANNANDALE VA
22003-1202
US

IV. Provider business mailing address

9104 ROARING SPRING LOOP
BRISTOW VA
20136-2109
US

V. Phone/Fax

Practice location:
  • Phone: 703-289-2781
  • Fax: 703-289-2764
Mailing address:
  • Phone: 703-392-1078
  • Fax: 703-289-2764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number0015000809
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: