Provider Demographics
NPI:1679008478
Name:CAMPBELL, DOMINEQ
Entity Type:Individual
Prefix:MS
First Name:DOMINEQ
Middle Name:
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 1:7063 N 37TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2360
Mailing Address - Country:US
Mailing Address - Phone:414-587-4991
Mailing Address - Fax:
Practice Address - Street 1:7063 N 37TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2360
Practice Address - Country:US
Practice Address - Phone:414-587-4991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-29
Last Update Date:2017-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health