Provider Demographics
NPI:1992118954
Name:CAMPBELL, TRACI SHAWNICE
Entity type:Individual
Prefix:MISS
First Name:TRACI
Middle Name:SHAWNICE
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 1:9415 GIBSON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-1729
Mailing Address - Country:US
Mailing Address - Phone:216-297-5786
Mailing Address - Fax:
Practice Address - Street 1:9415 GIBSON AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-1729
Practice Address - Country:US
Practice Address - Phone:216-297-5786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-07
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0084493Medicaid