Provider Demographics
NPI:1063375236
Name:CAMPBELL, CHENETRA
Entity type:Individual
Prefix:
First Name:CHENETRA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DWAYNE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17910 ESCANABA AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2118
Mailing Address - Country:US
Mailing Address - Phone:312-316-9212
Mailing Address - Fax:
Practice Address - Street 1:17910 ESCANABA AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2118
Practice Address - Country:US
Practice Address - Phone:312-316-9212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-04
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver