Provider Demographics
NPI:1477963254
Name:CAMPBELL, IMANI IFE (LPN)
Entity Type:Individual
Prefix:
First Name:IMANI
Middle Name:IFE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:IMANI
Other - Middle Name:I
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:323 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-4009
Mailing Address - Country:US
Mailing Address - Phone:917-870-0392
Mailing Address - Fax:
Practice Address - Street 1:323 SOUTH 10TH AVE
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550
Practice Address - Country:US
Practice Address - Phone:917-870-0392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300176-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY300176-1OtherLPN