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General NPI Number Information
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NPI Number | 1194493189
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Entity Type | Individual
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Provider Name | YANIQUE SHANTEL CAMPBELL
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Gender | Female
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Dates
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Enumeration Date | 09/02/2021
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Last Update Date | 03/21/2025
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Provider Practice Location Address
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Address Line | 4108 AVENUE U
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City | BROOKLYN
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State | NY
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Zip | 11234-5120
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Country | US
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Telephone | 832-485-4003
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Fax |
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Provider Business Mailing Address
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Address Line | 4108 AVENUE U
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City | BROOKLYN
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State | NY
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Zip | 11234-5120
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 032208
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 60771
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License Number State | CA
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