=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780072744
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACI KATHERINE CAMPBELL RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2014
-----------------------------------------------------
Last Update Date | 08/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 COLSON DR
-----------------------------------------------------
City | RUSSELL SPRINGS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42642-4587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-558-1818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 COLSON DR
-----------------------------------------------------
City | RUSSELL SPRINGS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42642-4587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 2034684
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 1173119
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------