Provider Demographics
NPI:1548010572
Name:CAMPBELL, TARA S (RN, BSN, CCM)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:S
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RN, BSN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14281
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29587-4281
Mailing Address - Country:US
Mailing Address - Phone:910-632-0325
Mailing Address - Fax:
Practice Address - Street 1:127 MARSH DEER PL
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6204
Practice Address - Country:US
Practice Address - Phone:910-632-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC205108171M00000X, 251E00000X, 253Z00000X, 163W00000X, 163WC0400X, 163WH0200X, 163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WX0106XNursing Service ProvidersRegistered NurseOccupational Health