Provider Demographics
NPI:1053874347
Name:CAMPBELL, MYRA S (APRN)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:S
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:S
Other - Last Name:GUILLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:2018 CLINCH AVENUE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2301
Practice Address - Country:US
Practice Address - Phone:865-541-8660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32161363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ077398Medicaid