=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174949671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANDICE S CAMPBELL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2014
-----------------------------------------------------
Last Update Date | 03/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7605 REGINA DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46815-8248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-413-5696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7605 REGINA DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46815-8248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-413-5696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BIRTH DOULA
-----------------------------------------------------
Name | CANDICE CAMPBELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 260-413-5696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374J00000X
-----------------------------------------------------
Taxonomy Name | Doula
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------