Provider Demographics
NPI:1730472358
Name:CAMPBELL, KENNETH JR (LPN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CAMPBELL
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18317 LEWIS DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-2734
Mailing Address - Country:US
Mailing Address - Phone:216-630-4713
Mailing Address - Fax:
Practice Address - Street 1:18317 LEWIS DR
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-2734
Practice Address - Country:US
Practice Address - Phone:216-630-4713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.140772-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse