Provider Demographics
NPI:1730847070
Name:CAMPOS, CATHERINE (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 S AZUSA AVE STE B-19
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-8004
Mailing Address - Country:US
Mailing Address - Phone:909-486-1207
Mailing Address - Fax:
Practice Address - Street 1:2080 S E ST STE 250
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2706
Practice Address - Country:US
Practice Address - Phone:909-486-1207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2022-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018291363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health