Provider Demographics
NPI:1073100186
Name:CAMPBELL, REAVONNE S
Entity Type:Individual
Prefix:MRS
First Name:REAVONNE
Middle Name:S
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 1:901 TOWER DR STE 420
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2827
Mailing Address - Country:US
Mailing Address - Phone:800-443-2603
Mailing Address - Fax:800-443-0403
Practice Address - Street 1:901 TOWER DR STE 420
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-2827
Practice Address - Country:US
Practice Address - Phone:800-443-2603
Practice Address - Fax:800-443-0403
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703123184164W00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide