=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518415652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH A CAMPBELL FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2016
-----------------------------------------------------
Last Update Date | 09/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 ELIZABETH ST
-----------------------------------------------------
City | UTICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13501-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-798-5748
-----------------------------------------------------
Fax | 315-798-1057
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 LORRIES LN
-----------------------------------------------------
City | WHITESBORO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13492-3228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-790-5975
-----------------------------------------------------
Fax | 315-792-7555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 339154
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------