=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629791843
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LENELL ANGELO CAMPBELL PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2022
-----------------------------------------------------
Last Update Date | 12/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 MACARTHUR BLVD
-----------------------------------------------------
City | MUNSTER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46321-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-836-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 335 W 9TH ST UNIT 1006
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46202-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-487-8850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 10003794A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------