MEDICARE: VANKETTIA RENELL CELESTINE

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	342000000X	Transportation Network Company

General Provider Information

NPI Number	:	1639910482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANKETTIA RENELL CELESTINE

Provider Business Mailing Address
First Line	:	4811 SUMMERHILL DR
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-2011
Country	:	US
Telephone Number	:	708-785-3528
Fax Number	:

Provider Business Practice Location Address
First Line	:	1934 W 79TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-5268
Country	:	US
Telephone Number	:	708-785-3528
Fax Number	:

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

Provider Enumeration Date	:	06/05/2024
Last Update Date	:	06/05/2024

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Directions to “ VANKETTIA RENELL CELESTINE ” Practice Location

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