=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043252174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN KENT CAMPBELL FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 08/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1367 DOMINION PLZ
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75703-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-534-6200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1367 DOMINION PLAZA
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-534-6200
-----------------------------------------------------
Fax | 903-939-0755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AP111386
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------