Provider Demographics
NPI:1508492125
Name:CAMPBELL, CAITLYN N
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:N
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 1:585 CUMNOCK RD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60067-4338
Mailing Address - Country:US
Mailing Address - Phone:847-436-2248
Mailing Address - Fax:
Practice Address - Street 1:15900 W 127TH ST STE 201
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-2912
Practice Address - Country:US
Practice Address - Phone:630-281-2496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-15
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008002133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered