MEDICARE: ELOISE CAMPBELL NP,CDE,BC-ADM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	3003087	KY
2	363LA2200X	Adult Health Nurse Practitioner	71001251A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3003087	OTHER	KY	STATE LICENSE
2	71001251A	OTHER	IN	STATE LICENSE

General Provider Information

NPI Number	:	1053474262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELOISE CAMPBELL NP,CDE,BC-ADM

Provider Business Mailing Address
First Line	:	3306 BREAUX DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-2113
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 DUPONT RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-4692
Country	:	US
Telephone Number	:	502-895-2334
Fax Number	:	502-896-6987

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	08/08/2013

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