MEDICARE: CHENETRA CAMPBELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver		IL

General Provider Information

NPI Number	:	1063375236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHENETRA CAMPBELL

Provider Business Mailing Address
First Line	:	17910 ESCANABA AVE
Second Line	:
City	:	LANSING
State	:	IL
Zip	:	60438-2118
Country	:	US
Telephone Number	:	312-316-9212
Fax Number	:

Provider Business Practice Location Address
First Line	:	17910 ESCANABA AVE
Second Line	:
City	:	LANSING
State	:	IL
Zip	:	60438-2118
Country	:	US
Telephone Number	:	312-316-9212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	12/04/2025

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Directions to “ CHENETRA CAMPBELL ” Practice Location

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