Provider Demographics
NPI:1144471699
Name:CAMPBELL, AMBER LEE
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:LEE
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 1:503 HIGHWAY 278 E
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71701-8605
Mailing Address - Country:US
Mailing Address - Phone:870-836-1346
Mailing Address - Fax:
Practice Address - Street 1:503 HIGHWAY 278 E
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-8605
Practice Address - Country:US
Practice Address - Phone:870-836-1346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2185171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR169027721Medicaid