Provider Demographics
NPI:1427773175
Name:CAMPBELL, CHARLENE CENTALIA
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:CENTALIA
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 1:21971 S LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-2166
Mailing Address - Country:US
Mailing Address - Phone:216-758-0281
Mailing Address - Fax:
Practice Address - Street 1:21971 S LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-2166
Practice Address - Country:US
Practice Address - Phone:216-758-0281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401456141112374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide