Provider Demographics
NPI:1528304268
Name:ANDERSON, CAMILLE KELLY
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:KELLY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5556 BROADVIEW RD
Mailing Address - Street 2:3509
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-1634
Mailing Address - Country:US
Mailing Address - Phone:216-624-2830
Mailing Address - Fax:
Practice Address - Street 1:5556 BROADVIEW RD
Practice Address - Street 2:3509
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-1634
Practice Address - Country:US
Practice Address - Phone:216-624-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401025750110374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide