Provider Demographics
NPI:1366674467
Name:STACKHOUSE, CAMILLE N (PA)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:N
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7271 S SOUTH SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-2893
Mailing Address - Country:US
Mailing Address - Phone:773-314-7090
Mailing Address - Fax:
Practice Address - Street 1:855 E GOLF RD
Practice Address - Street 2:SUITE 2133
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-5222
Practice Address - Country:US
Practice Address - Phone:847-290-9122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-23
Last Update Date:2009-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.003540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant