Provider Demographics
NPI:1922195478
Name:CAMPOBELLO, MARIE LOUISE (PA-C)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:LOUISE
Last Name:CAMPOBELLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 FREEMAN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3536
Mailing Address - Country:US
Mailing Address - Phone:617-730-2954
Mailing Address - Fax:
Practice Address - Street 1:127 FREEMAN ST APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3536
Practice Address - Country:US
Practice Address - Phone:617-730-2954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant