Provider Demographics
NPI:1053897090
Name:CAMPBELL, AMY RAE
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:RAE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 VAN BUREN AVE NE
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73078-9634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 NW EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4999
Practice Address - Country:US
Practice Address - Phone:405-949-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL-143273163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant